Frienfls  o?  the  Insane 
and  Other  Essays 


BAYARD   HOLMES 


THE  LIBRARY 

OF 

THE  UNIVERSITY 
OF  CALIFORNIA 

LOS  ANGELES 

Gift  of 
Dr.  Gustav  F.  Buediger 


THE  FRIENDS  OF  THE  INSANE 

THE  SOUL  OF  MEDICAL  EDUCATION 

AND  OTHER  ESSAYS 


BY 


BAYARD  HOLMES,  M.D. 
CHICAGO 


CINCINNATI : 

THE   LANCET-CLINIC   PUBLISHING    COMPANY 
1911 


Romedical 
Library 


w 

1 

Hr/ 


The  following  essays  are  corrected  reprints  from  the 
pages  of  the  Lancet-Clinic.  Some  brief  additions  have 
been  made  to  them  for  completeness  or  clearness. 
They  were  written  with  a  distinct  purpose. 

It  has  seemed  very  unreasonable,  not  to  say  cruel, 
that  the  insane  are  cared  for  by  the  State,  not  for  their 
own  good,  but,  as  Dr.  George  Webster,  President  of 
the  Illinois  State  Board  of  Health  once  said  at  a  ban- 
quet of  a  medical  fraternity,  for  the  good  and  safety 
of  the  sane.  Millions  are  spent  in  custody,  but  not  a 
dollar  in  cure,  not  a  dollar  in  research.  If  the  man  of 
business,  the  stock  farmer,  for  example,  lost  one  out 
of  every  300  of  his  creatures  by  an  expensive  disease 
or  accident,  and  continued  caring  for  these  sick  ani- 
mals at  great  expense,  making  no  effort  to  discover 
the  source  of  the  disease  or  do  away  with  the  cause  of 
the  accident,  he  would  be  in  the  position  of  the  forty 
sovereign  States  that  care  for  the  insane  but  make  no 
effort  to  discover  and  eradicate  the  cause. 

For  every  thousand  dollars  spent  in  custody  ten  dol- 
lars ought  to  be  spent  in  research.  Economy  might 
dictate  that  even  a  hundred  dollars  out  of  each  thou- 
sand should  be  spent  in  research  and  cure.  As  it  is, 
absolutely  no  effort  is  made  by  any  department  of 
State  to  shut  off  the  need  of  an  expense  for  custody 
of  the  insane,  which  is  as  much  a  burden  to  industry  as 
a  perpetual  war. 


."031 


iv  ESSAYS. 

It  is  my  belief  that  this  work  of  investigating  the 
causes  of  insanity  should  be  carried  on  by  the  univer- 
sity. The  problem  seems  to  be  one  of  biologic  chem- 
istry. The  chemical  libraries  and  trained  chemists  and 
biologists  are  already  crowded  about  the  university.  The 
precedent  of  associating  the  agricultural  experimental- 
stations  with  the  State  university  has  opened  the  way, 
and  the  prospect  of  great  economic  benefit  to  the  State 
has  been  demonstrated  by  the  work  of  the  Department 
of  Agriculture.  If  the  various  departments  of  State 
charity  and  correction  could  be  under  the  scrutiny  of 
a  scientific  body  of  imaginative  investigators,  the  need 
of  many  millions  for  custody  and  correction  could  be 
eliminated  (Rhodes).1 

The  insane  themselves  cannot,  for  various  and  ob- 
vious reasons,  present  their  claims.2  The  friends  of 
the  insane  have  never  been  organized  for  their  own 
protection,  education  and  consolation.  There  seems  to 
be  a  strange  isolation  in  the  fact  of  insanity  in  the 
household.  For  death  and  for  the  bereaved  by  death 
there  is  ostentatious  sympathy  and  consolation  from 
friends  and  strangers  and  the  world  of  literature.  For 
the  bereaved  by  insanity  there  is  a  fateful  silence  and 
turning  away.  There  is  every  reason  why  the  friends 
of  the  insane  should  be  thoroughly  organized  into  a 
great  executive  and  educational  body.  The  commit- 
ment of  the  insane  is  in  many  States  a  relic  of  bar- 
baric legal  procedure  and  should  be  corrected.  In 

1  Rhodes:  Internationaler  Kongress  fur  Irrenpflege.    Wien, 
Oct.,   1908.     Offizieller  Bericht. 

2  Beers,  C.  W. :  A  Mind  that  Found  Itself.     Macmillan  & 
Co.,  1908.    8vo,  pp.  363. 


PREFACE.  v 

every  State  the  custody  of  the  insane  is  conducted 
under  ideal  conditions  for  the  promotion  of  tubercu- 
losis. There  is  no  State  institution  where  adequate 
encouragement  is  provided  for  the  study  of  the  causes 
of  insanity  or  of  the  conditions  of  parasitism,  hemol- 
ogy,  nutrition  and  metabolism  during  the  course  of  the 
disease.  There  is  no  State  in  which  the  insane  are 
available  for  demonstration  to  medical  societies  and 
medical  students.  The  ordinary  means  of  studying  in- 
sanity, which  medical  men  have  in  studying  all  other 
diseases,  is  taken  away  from  the  medical  profession  by 
law,  and  no  other  provisions  are  made  at  all  commen- 
surate with  the  importance  and  the  complexity  of  the 
problem. 

The  problem  of  the  insane  is  intricately  associated 
with  the  problems  of  crime,  prostitution  and  poverty, 
as  well  as  with  the  problems  of  hospital  management, 
education  and  all  political  economies.  A  considerable 
proportion  of  the  insane  first  manifest  their  disease 
by  acts  that  bring  them  into  conflict  with  the  police. 
The  courts  should  be  provided  by  the  friends  of  the 
insane  with  a  questor  or  advocate  for  the  insane,  whose 
duty  it  should  be  to  call  the  attention  of  the  court  to 
such  evidence  as  might  early  lead  to  the  treatment  of 
cases  of  incipient  insanity,  such  as  the  State  now  pro- 
vides, and  thus  save  the  judiciary  from  the  bungling 
decisions  which  so  often  confound  the  officers  of  penal 
institutions.  If  an  organization  of  the  friends  of  the 
insane  did  nothing  more  than  provide  an  advocate  for 
the  insane  in  criminal  courts  and  police  courts,  the 
reason  for  such  an  organization  would  soon  be  ad- 


vi  ESSAYS. 

mitted  by  all  whose  complacency  would  be  disturbed 
by  the  innovation. 

When  insanity  comes  to  a  household,  there  is  noth- 
ing that  is  too  expensive  to  be  undertaken.  The  pri- 
vate sanitarium  is  recommended  by  alienists  because 
the  family  dread  and  are  terrified  by  the  State  insti- 
tutions. The  expense  at  these  private  places  is  very 
high — fifty  to  two  hundred  dollars  a  week.  Nothing 
commensurate  with  the  price  is,  however,  furnished. 
The  attendants  work  for  fifteen  to  thirty  dollars  a 
month.  There  are  no  laboratories,  baths  or  skilled 
attendants.  The  folks  who  look  upon  surroundings 
of  luxury  as  more  important  than  the  researches  which 
reason  dictates  will  always  patronize  these  places, 
where  brass  door  knobs  and  Brussels  carpets  take  the 
place  of  bolts  and  bare  floors.  If  a  small  part  of  the 
largess  poured  out  on  the  unsanitary,  unnecessary  and 
unappreciated  display  of  the  private  rnad-houses  was 
devoted  to  research,  something  could  be  accomplished 
by  private  initiative,  and  that  promptly.  It  should  be 
the  duty  of  an  organization  of  the  friends  of  the  in- 
sane to  warn  any  but  the  very  rich  against  the  private 
sanitarium,  and  dissuade  them  from  their  prejudices 
against  the  State  institutions. 


SUBJECT  INDEX. 


PAGE 

Abortion,  contagious,  of  cattle Ill 

Academy  of  Medicine  of  New  York 151 

Acute  infections  and  insanity,  before  the  court 10 

Acetone  in  dementia  precox 31 

Adolescence — 

dangers   in    47 

metabolic  changes  in 47 

dementia  precox  in 7,  24,  48 

Adolescent  insanity  (see  dementia  precox). 

Board  of  Administration  of  Illinois 113 

Africa  and  the  sleeping  sickness 23 

Agricultural  Department  and  the  hookworm  disease 22 

its  experiment  station 136,  159,  237 

its    expenses    136 

Agglutinative   tests   in   the   diagnosis   of   diseases    of   ani- 
mals   89,  97 

Acapnea     253 

Admission  to  medical  schools 165-168 

Alcohol  and  insanity 21 

Alkaptonuria,  a  recognizable  error  of  metabolism 55,  93 

Alienists  (see  psychiatrists). 

conceptions  of  insanities 4,  25,  44,  48,  50 

Albinism,  its  analogies  to  the  diseases  of  which  insanity 

is   symptomatic    59,  66 

and  Mendelism   61 

American   Medico-Psychological  Association 24 

American  Medical  Association — 

its  influence  on  literature 153 

Anemia   and   insanity 20 

Apnea  and  shock 253,  257 

Arthritis  deformans 38 

Artificial  hyperemia  41 

Artificial  streptococcus  infection 40 

Asiatic  cholera,  psychic  origin 1 18 

Asylum  (see  hospital). 

lunatic  43,  44 

custodial    101 

population  in  United  States 86 

expense  of    86 

waves  of  reform    101 

attendants   2,  3.  113 

orphan,  death  rate  'in 171 


PAGE 

Association  of  American  Medical  Colleges 127 

Atrocities  of  police  on  the  uncommitted  insane 18 

Attendants  at  hospitals  for  insane 1 

Australia    without    an    orphan 201-206 

problem    of   defective   child 171 

Baths   and   insanity 35 

Bateson's  translation  of   Mendel 208 

Bedbugs  in  asylums  and  barracks 23 

Beriberi 117-124 

Bertillon  identification    29 

Bile-ducts,  congenital  obliteration  247 

Blackwater  fever   22 

Blood  of  the  insane. 37,  40,  45,  89 

Board  of  Administration,   Illinois 112 

Books   and   bookstores 193 

Boston  Medical  and  Surgical  Journal 157 

Brain,  concussion  of,  followed  by  hysteria 68 

Bread  line  and  crime  against  property 9 

British  Isles,  educational  system  of 127 

British  Medical  Journal  156 

Burmah    23 

Catatonia,  recovery  from 40 

Causes  of  insanities,  study  of 27 

Caxton's  chivalry  and  orphans 169 

Cerebro-spinal  meningitis 84 

Cholecystitis  in  degenerates 251 

Cholera   infantum    244 

Christian  Science 5,  21,  33,  44,  69,   111,  227 

Chicago,    commitment    methods    in 

Neurological    Society 197 

Tribune  reoort  of  New  York  police  methods 11 

Cherry  coal  mine 112 

Chemiotaxis    105 

Chemistry,  physiological 35 

Charities,  service  of  State  institutions 113 

China,  University  of 157 

Cincinnati,  new  medical  school 158 

Civil  Service  in  hospitals  and  State  institutions 30,  145 

Claim  agents  of  railways 68 

Coaguability  of  the  blood  in  the  polycythemia  of  the  in- 
sane      41 

Code  of  Charities  in  Illinois 108,  109.  113,  1 14 

Cook  County,  Illinois 15,  17 


INDEX.  ix 

PAGE 

Cobra  venom  reaction  in  diagnosis  of  dementia  precox 40 

Colleges  of  agriculture 139 

Coley's  toxin   40 

Commission,  Royal  of  England,  on  defectives,  delinquents 

and  dependents  7 

Commitment  a   horror 1,    17 

legal  practice  of  in  Cook  County,  Illinois IS 

witness,   rights  not  considered 17 

Conscience  of  the  State  in  university  of  State 142 

Contagious  abortion  Ill 

Council  of  Medical  Education  of  American  Medical  As- 
sociation     128 

Courts,  revenge  of 10 

Crimes,  committed  by  insane  9 

Cure  or  custody 30 

Cure  precedent  to  punishment 10 

Cystinuria,  a  condition  of  error  in  metabolism 94 

Dairymen's  Association  and  epidemic  contagious  abortion 
of  cattle Ill 

Detention  hospital   15 

Delinquent  insane,  torture  of 7,  11 

Dementia  precox  29,  31,  33,  46,  48,  96,  117 

Deforming  osteitis   53 

Delirium    tremens    81 

Defense,  medical    149 

histories  of  insane  for 2 

Department  of  Agriculture 237 

Disease,  physical  signs  of ,••• 33 

Diamines   93 

Diaminuria,  a  symptom  of  an  error  in  metabolism 95 

Diphtheria    224 

Divorces  in  Iowa 216 

Donovan  body  in  kala  azar 23 

Dope  fiends  and  insanity • 21 

Doctors'  opportunities   147,  240 

Eclampsia  a  toxemia 46 

Education,  medical    • .  149 

Emmanuel  movement 44,  69,  227,  243 

Epidemic  ».-. 40 

Epilepsy  relation  to  insanity  and  hysteria. 68 

Erysipelas    • •  •   26 

Enteritis   250 

Eugenics    , •  • 69 


x  ESSAYS. 

Expense  of  army  and  navy —  PAGE 

of    agricultural    schools 138 

of    agricultural    department 

of  custodv  of  insane t 

of  engineering  schools   139 

of   feeble-minded    •  •  • 78 

of    medical    education 137 

of  research  into  diseases  of  animals  and  plants 

Farming  as  a  profession 238 

Fatigue  a  toxic  process 35 

Feeble-minded  causes   • . .   71 

civil  rights    i 77 

prevention  •••...  73 

ratio   to   normal 76 

significance  to  labor  problem 78 

Fletcherism   669,  243 

Focke,  his  reference  to  Mendel 209 

Friends  of  insane. .  • •  • 1 

assessed  in  Cook  County 16 

duty   to   organize , •-....     5 

establish  fellowships  of  research 30 

Fractures  of  the  skull  and  the  police 11 

Fragillis  osseum    • •  • 38 

Freud,  theory  of  insanity •  • -.110 

French  Republic  educational  system •  • 127 

Gangrene 43 

hospital  exterminated   224 

Garfield,  insane  murderer  revenged 10 

General  paresis  not  due  to  a  twisted  idea 21 

Goiter  exophthalmic 25 

Gonorrhea    • .  •  • 218 

Gumma,  hepatic    73 

Harrison  street  police  court 16 

Harvard  Medical  School 133 

Head  iniuries  and  disturbance  of  cerebration 68 

Hematology  45 

Hemolysis  • 105 

Hepatic  gumma  73 

Heredity  (see  Mendelism). 

in  defectives 25,  33 

Hookworm  disease  20,  92,  229 

and  insanity  85 


INDEX.  xi 

Hospitals  for  insane — •  PAGE 

pyschppathic  36 

rid  of  gangrene  and  erysipelas 43 

Hyperpnea  255 

Hyperthyroidism   and    insanity 21 

Hypophepeal  disease    104 

Hysteria  after  injury  of  the  head 68 

Idiots  (see  feeble-minded). 

congenital    71 

Immunization • 105 

Infantile  paralysis    48 

Inquisition  of  police  on  insane  delinquents 13 

Insane  and  insanity — 

adolescent  (see  dementia  precox). . .  • •  • ,. .  48 

asylums  (see  hospitals  in  China) 99 

barbarous  nations  and 99 

duty  of  State  to  cure 86 

etiology •  • 99 

expense  of  custody 103 

segregation    49 

puerperal     •  • 47 

pyschosjenitis  origin  of  (see  Freud). 

Institute  of  Pyschosity,  code  of  charities 106,  110 

Institution — 

custodial   2 

staff -..  3 

State  and  private  4 

Illinois,  treatment  of  insane 15,  18,  105 

State  Board  of  Health  of 161 

Iowa,  decrease  of  population 213 

Japanese  and  beriberi 1 19 

Jaundice    247 

congenital 56,  65,  247 

chronic  •  • • 55 

malignant   > 46 

with  overgrowth  of  bone 54 

symptomatic   247 

toxic,   of  pulmonary  disease ••....  55 

Johns  Honkins  University 165 

Journal  of  American  Medical  Association 106,  157 

Jung  inquisition       15,  110 

Justice,  administration  of 9 

Kala-azar   , 20,  23 

Kankakee,  institution    .  108 


xii  ESSAYS. 

PAGE 

Kitchen  laboratory 34 

Kneip  nature  cure 69 

Laboratories 30,  31,  135-146 

equipment  of 112,  135-I4O 

Libraries    31 

Lamziekte,  a  disease  of  cattle 90 

Leucopenia    22 

Lincoln,  insane  murderer  of,  revenged 10 

Liver,  acute  yellow  atrophy  of 46,  47 

Lunacy,  psychogenetic,  origin  of 105 

McKinley,  insane  murderer  of,  revenged 10 

Mad  houses 1,  43,  44,  48,  49,  85 

Malaria  cachexia 22 

Malignant  edema r •  • . .  26 

Medical  education 125,  133,  170 

medical  hygiene 177 

literature  56,  185,  194 

pedagogy  • 133 

research  187 

schools,  absence  of  physical  examination  on  entrance.  .177 

cost  of  169 

entrance  examinations 167,  168 

relation  of  to  the  university 165 

resources   compared   with   other  professional  schools, 

169,  170 
students  of,  169,  177. 

Medical  School  of  University  of  Michigan 157 

Medical  teacher,  necessary  examination  of 129,   155 

profession,  become  unionized 158 

Colleges,  Association  of  American 151 

societies 181,  185 

Melena  neonatorum  •  • 38 

Mendel   and   Mendelism 61,  207 

Mental  diseases,  study  of  etiology  of 46 

Mental  tangles 44 

Metabolism,  errors  of 55,  110 

Methemoglobinemia  in  dementia  precox 41 

Methyllike  toxemia 31 

Michigan,  Psychopathic  Institute  of 24,  104,  114 

University  of   157,  161 

Mountain  fever 23 

Mutism    diminished    by    preventing    epidemics    of    scarlet 

fever  120 

Myositis  ossificans   38 


INDEX.  xiii 

PAGE 

Myxedema,  insanity  of 21 

Neurasthenia  84 

New  York  Psvchopathic  Institute 24,  103,  109,  114 

University  of  State  of 161 

Novelists'  attitude  toward  insane 201 

Nurses  in  hospitals  for  insane 2 

Orphanotrophies  201 

Orphanage  201-206 

Osteitis  def  ormans  53 

Osteomalacia 31,  38,  41 

Osteophytes  •  •  53,  55 

Paresis,  general > • 48 

Pedagogic  method  in  medical  schools 136 

Pellagra 26,  39,  85,  101,  110,  115,  125-134 

Periarthritis,  syphilitic  52 

Paraostitis,  ossifying 52 

Pernicious  anemia 38 

Personal  liberty  17 

Philadelphia  bookstore  158 

Phipps  endowment  for  the  study  of  insanity 24 

Piroplasma  22 

Poisoning,  phosphorous  46,  47 

delaved  chloroform  26 

Police,  their  treatment  of  delinquents 11.  18 

Polycythemia  in  dementia  precox 41 

Pseudo-sciences  69 

Psychiatry,  the  new 102 

Psychiatrists 1,  5.  45 

Psychical  manifestations 33 

Psychological  institutes  and  hospitals 109,  114 

laboratory  135 

Psychogenesis >. .  103 

Pyosalpinx  218 

Recovery  of  insane  after  tyohoid,  erysipelas  and  other  in- 
fections    39 

Rural  life,  standards  of 235 

Responsibility  of  insane   i •  • .     9 

Royal  Commission,  ei^ht  blue  books  on  insane 75 

School  houses  in  rural  districts 239 

Senility    •  • • • 35 

Septic  tank  •  • i 229 

Serology 43 

Sewerage  disposal 230 

Sleeping  sickness  • •  • 23,  35 


xiv  ESSAYS. 

PAGE 

Societies  for  homing  children 172 

Spirocheta  pallida 33 

Spondylosis  rhizonelic 3, 6 

Strangles   ' 91 

Starvation  at  the  end  of  insanity 101 

Stockmen    Ill 

Syphilitic  insanities 33,  81,  218,  248 

Teas    22 

Sweat-box • 11 

Tea  ^ardens  of  Assam 23 

Theological  schools,  endowments 169 

Third  desree  for  the  insane 11 

Tick  fever •  • 23 

Torture  illegal  of  insane  suspects 11 

Toxemias 27 

in  nregnancv  47,  38 

unexplained 55 

Tropical  diseases  23 

Trypanosome  (see  sleeping  sickness) 20 

Tuberculosis 26,  85,  101,  224 

Typhoid 10,  26,  218,  223,  229 

State  universities,  duty  of  toward  defectives,  delinquents 
and  dependents 118,  141,  122,  119 

United  States,  insane  population  of 34 

public  schools  of   127 

Virginia,   University  of 157 

Von  Langenbeck  House  in  Berlin 151 

Wasserman  reaction 73,  248,  251 

Water  treatment •  • 11 

Wayne  County,  Iowa 213 

Widal  reaction  22 

Welcome  laboratory 23 

Wisconsin,  attitude  toward  the  insane 101 

Wisconsin,   University  of 138,  144,    157 

West  Point  138 

Workshops    •  • 35 

Wound  infections  224 

Yellow  fever   .  .  23 


INDEX. 
INDEX   BY   AUTHORS. 


PAGE  PAGE 

Adler   63    Dussonville  91 

^Esculapius    158,    195    Ehrlich 81,113,143 

Agassiz    207   Faraday   207 

Agostini 37   Farabee  60 

Allison 8   Fieux 46,  47 

Amselee   68   Flexner 113,  143 

Ashford    21    Focke  209 

Austrezverels    85   Frerichs    47 

Babcock    128   Freud  4,  31 

Baelz    120   Gage 85 

Bass     85    Galen   195 

Bateson   60   Galvani    207 

Bok   69   Geissner   247 

Bonnier   209   Gibson   41 

Boody    40    Golazzo   85 

Boyle 81    Goddall   40 

Brocksrnith     126    Gould    60,  61 

Bullin    40   Green. 84 

Burton  37   Grosskurth  54 

Biittenmiller   54   Gunn  63 

Buzzi    63    Haacke     62 

Campbell    25,    40   Halcase  120 

Carroll     153    Halstead   198 

Castle   61,  62   Harrison    37 

Caxton 203    Hecht    ....199 

Channing    243    Heighet  123 

Cini   37   Heiser   122 

Clark    131    Hektoen    143 

Clark,  Miss  204    Henderson  253,  256 

Clarke    68   Herzog  120 

Coinde  60    Heverech-Kobliha  37 

Columbus    201    Hippocrates   195 

Cuenot   61,  64   Holzman  40 

Cuvier   207   Homer  202 

Correns 207,210   Horiuchi   120 

D'Abundo  37   Hyde    60 

Darwin 60,  63,  81,  207    Imgaki  120 

Darbishire  62   Janet  68 

Davis   195   Johnson 205 

Desottvry  91    Jung 31 

De  Vries  207   Kanavel   198,  199 

Duncan    214   Keller 19,79 

Durham,  Miss  64   Koch 81,  117,  143 


<vl  ESSAYS. 

PAGE  PAGE 

Kokubo  120  Raphael    207 

Kraepelin    153   Ricketts    23,   153 

Krypiakiewicz  37   Robertson  91 

Lamb   19   Rockefeller   229 

Lambranzi 37   Rollston   52 

Larrey  26   Roncoroni    37 

Lazear   153   Roosevelt    235 

Lemann  84   Savage 39 

Lewis  199   Schultz  91 

Lindsay  37    Seppelli   37 

Lister 26,  43    Scheube    120 

Livi   59   Semon    95 

Loos  22    Shadwell    129 

Mackie   37    Shiller,   Max 117 

Manslessei  131    Shurtliff  141 

Marcy    61    Smith  22 

Marriott    95    Smyth  37 

Mathews   199   Socrates 201,207 

Mauriac   46   Spence,  Miss  204 

May 24   Stanley  24 

McCarty   214   Strabo   188 

Mclntosh  63    Stevenson     59 

Mendel  207    Summers    37 

Mercier  82   Sydenham   153,  195 

Metchnikoff   143    Symm  60,  63 

Michael  Angelo  207   Takaki    119 

Moore   24  Thompson. . .  .50,  247,  249,  250 

Mooso   253   Tanaka    123 

Much   40  Tregold  74 

Mudge  64  Tydall  81 

Memori    120   Tschermark  207,210 

Nadler  54  Von  Norten  55 

Newton  81   Vester 37 

Novey    113   Veit  47 

Okato 120   Virchow  53 

Page 84  Von  Guaite   62 

Parks  153   Von  Langenbeck  43 

Pare  153   Wasserman  251 

Pasteur 26,  43,  143   Weber   37 

Pearson 63   Welch  113 

Peter 209  Wetzel  249 

Phideas   201    Wherry  y 

Pollock  131    White   214 

Price  23   Wolf  95 

Punnet   208   Wright 120,123 


INSANITY 


THE  FRIENDS  OF  THE  INSANE. 


THE  FRIENDS  oi  the  insane  are  in  a  most  pitiable 
condition.  The  event  of  insanity  in  the  family  is 
unprecedented  and  unprovided  for.  The  doctor  is 
called,  and  he,  too,  is  "up  against  it."  He  knows 
as  well  as  the  family  that  the  boy  is  crazy.  More  than 
this  he  knows  no  better  than  they.  He  calls  a  psy- 
chiatr'st,  whose  complete  armamentarium  consists  of 
a  percussion  hammer,  a  pair  of  dividers  and  a  glass 
tube.  He  gives  a  name  to  the  disease,  itself  most  om- 
inous, a  shadow  of  prognosis,  recommends  an  expen- 
sive private  sanitarium,  collects  an  unequalled  fee, 
and  complacently  departs. 

If  the  patient  must  be  legally  committed,  another 
horror  is  added  to  the  natural  anguish  consequent  to 
the  disease.  The  distracted  patient  must  be  brought 
to  court,  and  from  that  time  until  the  doors  of  the 
madhouse  close  upon  him  he  is  in  the  hands  of  the 
sheriff  and  in  the  position  of  a  convict,  frequently 
handcuffed  to  an,  at  best,  ignorant  deputy. 

Most  madhouses,  lunatic  asylums  and  retreats  are 
now  called  "hospitals  for  the  insane,"  or  even  "State 
hospitals,"  with  the  word  insane  left  out  altogether. 
This  is  a  species  of  hypocrisy,  as  we  shall  later  show, 
but  it  has  the  hope  of  the  hypocrite  in  it,  namely,  the 
recognition  of  righteousness.  They  should  be  hospi- 
tals— every  bit  hospitals.3 

3  Thirty-five  States  use  the  word  hospital,  twelve  of  them 
(California,  Delaware,  Georgia,  Illinois,  Iowa,  Kansas,  Min- 

I 


2  ESSAYS. 

The  ancient  implements  of  inquisitorial  torture 
and  some  of  the  modern  armament  of  restraint  are 
absent  from  these  colossal  frauds,  but  implements 
of  assault  upon  the  disease — the  laboratories,  the 
squads  of  laboratory  workers;  the  clinical  kitchens 
and  the  squads  of  clinical  chefs;  the  bath  rooms  and 
the  squads  of  nurses  and  masseurs — are  nowhere  to 
be  found.  Behind  the  doors  of  a  custodial  institution 
the  crazy  boy  is  shut;  the  key  turns  the  bolt,  and  all 
else  is  left  to  fate. 

The  attendants  in  the  public  and  private  asylums 
for  the  insane  are  not  nurses  of  any  sort  or  kind. 
They  have  no  education,  no  training  and  no  esprit  de 
corps.  One  was  a  farm  boy,  one  a  livery  driver  who 
wanted  to  get  out  from  the  cold;  one  was  a  bell  hop 
who  was  committed  to  one  asylum  drunk  and  took 
up  nursing  at  another ;  and  so  on,  diminuendo  ad  finem. 
The  females  are  no  better,  but  they  need  not  be  char- 
acterized.4 In  most  institutions  they  seem  to  think 
themselves  turnkeys.  They  take  instructions  from  the 
doctors,  and  in  the  best  managed  institutions  carry 
out  these  directions,  which  are,  for  the  most  part, 
for  sedatives  and  laxatives.  Histories  and  records  are 
kept  for  legal  purposes,  for  institutional  self-defense. 

nesota,  New  Hampshire,  New  York,  Ohio  and  Virginia)  with- 
out the  word  insane ;  thirteen  use  asylum,  thirty  use  insane ; 
one  each  use  sanitarium,  mental  and  mental  diseases  in  nam- 
ing their  institutions.  England  still  uses  lunatic,  but  her  colo- 
nies have  abandoned  that  word. 

4  "The  pay  is  such  that  nothing  better  can  be  expected ;  $20 
to  $30  per  month  is  the  average.  Tips  and  other  graft,  such 
as  patients'  coats,  shirts  and  shoes  hardly  attract  desirable 
servants." — v.  Barrus :  "Nursing  the  Insane.  8vo.  1908.  P.  3. 


FRIENDS  OF  THE  INSANE.  3 

The  handwriting  and  spelling  -show  the  turnkey's 
neglected  schooling.  The  condition  of  his  wards  shows 
his  equipment  as  a  turnkey. 

The  house  staff  in  one  of  our  best  institutions  has 
routine  duty  laid  out  to  fill  at  least  eight  hours  a  day. 
The  duties  are  distinctively  routine.  Thus  they  re- 
semble the  similar  duties  in  a  prison.  The  attitude  of 
the  individual  makes  some  difference  in  the  time  con- 
sumed and  in  the  quality  of  work.  But  there  is  no 
time  or  place  or  equipment ;  no  motive  or  direction  in 
any  of  the  possible  researches  into  the  daily  history 
of  the  insane,  the  causes  of  insanities  and  the  meth- 
ods of  treatment  or  possibilities  of  prevention.  Few 
good  men  stay  in  the  service  long.  It  suits  only  a 
misanthrope  or  pessimist.5 

The  superintendents  are  another  class  of  highly  spe- 
cialized individuals.  They  are  generally  pretty  big  men, 
smooth,  cautious,  conservative,  drifting  with  the  tide, 
reforming  sidewalks  about  their  institutions  with  great 
boasting  and  flourish,  while  they  let  the  patients  starve 
to  death  or  die  of  infectious  or  rotten  food.  They 
save  at  the  spiggot  while  they  spill  at  the  bung.  But 
their  way  is  beset  by  many  dangers  and  difficulties. 
The  horde  of  politicians,  from  the  senators  and  the 
speaker  of  the  house  down  to  the  local  ward  heeler, 
hang  to  him  like  bloodsuckers  to  get  graft,  favor  or 
preferment.6  He  must  be  something  of  a  genius  to 

5  New  York,  Report  State  Commission  in  Lunacy.     1904, 
p.  38. 

6  See  the  Report  of  Legislative  Committee,  Investigation  of 
Illinois  State  Institutions;  Forty-fifth  General  Assembly.    1908. 
Large  Svo,  pp.  1002. 


4  ESSAYS. 

keep  the  pack  off  and  yet  keep  them  in  good  spirits. 
He  must  play  their  game  and  yet  keep  clean  enough  to 
withstand  the  periodic  scandalous  investigations  which 
the  perfectly  legitimate  incidents  of  an  asylum  for  the 
insane,  now  and  then,  when  the  political  waters  are 
troubled,  excite  a  legislature  to  fix  upon  as  atrocities. 

The  State  is  very  parsimonious,  not  to  say  stingy, 
in  the  care  of  the  segregated  insane.  The  most  civ- 
ilized and  richest  States  keep  the  insane  on  about 
fifty  cents  a  day.  Some  of  the  States  have  model  in- 
stitutions that  shove  it  down  to  twenty-nine  and  a  half 
cents.  In  the  whole  United  States  the  tendency  is 
toward  the  half-dollar  rate.  Now  what  kind  of  thera- 
peutics can  you  expect  for  fifty  cents?  Laboratories, 
kitchens,  baths,  occupational  gymnasiums,  can't  be  pro- 
vided at  such  rates. 

The  friends  of  the  insane  have  no  choice,  either  with 
State  or  private  institutions.  They  may  pay  more  or 
less,  but  they  can  get  no  therapeusis.  All  alienists 
look  upon  insanity  as  our  medical  ancestors  looked 
upon  tuberculosis — as  an  hereditary  fault,  a  curse  of 
God.  Not  only  is  the  sufferer  cursed,  but  his  family, 
even  to  the  third  and  fourth  generation,  forward  and 
backward.  The  parent  of  an  insane  boy  is  not  able, 
be  he  rich  or  poor,  wise  or  ignorant,  to  do  what  he  can 
in  almost  any  other  sickness — get  thorough  investiga- 
tion and  daring  therapy.  There  are  some  so-called 
alienists  who  look  upon  insanity  as  twisted  thinking. 
The  followers  of  Freud  try  to  untangle  the  twisted 
ideas  and  thus  cure  the  patient.  They  don't  try  this 
on  the  aged,  on  the  so-called  general  paretic,  on  the  in- 


FRIENDS  OF  THE  INSANE.  5 

sanities  after  child-birth,  or  on  the  alcoholic;  but  in 
selected  cases  they  achieve  wonderful  cures!  So  do 
the  Christian  Scientists.  In  fact,  this  whole  idea  of 
insanity  is  a  scientific  vocabulary  and  method  applied 
on  Christian  Science  principles. 

The  only  reasonable  hope  the  friends  of  the  insane 
boy  have  is  that  he  may  get  well,  willy  nilly.  Some 
do  —  the  psychiatrists  say  two  to  ten  out  of  each 
hundred — and  afterward  "make  very  useful  citizens." 
No  treatment  must  be  expected.  The  resources  of  the 
State  and  the  psychiatrists  are  exhausted  in  custody, 
in  institutionalism  and  in  red  tape. 

But  why  shouldn't  the  friends  of  the  insane  organ- 
ize an  offensive  and  defensive  society — a  society  to 
secure  and  give  information  and  consolation  to  the 
friends  of  the  insane  during  the  first  shock  of  the 
calamity,  during  the  years  of  struggle  against  cruel 
fate,  and  in  the  desolation  of  lost  hope ;  a  society  to 
protect  the  officers  of  the  hospitals  of  the  insane  from 
political  persecutions  and  newspaper  defamations;  a 
society  to  constantly  inspect,  supervise  and  formally 
criticize  the  conduct  of  every  department  of  these  pub- 
lic undertakings ;  a  society  to  demand,  encourage  and 
further  the  study  of  insanity  as  a  symptom  of  many 
sick  people,  its  early  detection  and  its  ultimate  cure;  a 
society  to  disseminate  information  as  to  the  true 
import  of  insanity  in  its  various  forms;  a  society  to 
do  useful  things  for  the  insane  and  the  equally  unfor- 
tunate friends  of  the  insane? 


SHALL  WE  CONVICT,  SENTENCE  AND  PUN- 
ISH, OR  COMMIT,  CARE  FOR  AND  CURE 
THE  INSANE  DELINQUENT? 


WHEREVER  society  or  civilization  touches  health  and 
disease  the  medical  man  may  make  no  apology  to  enter. 
Indeed,  if  he  does  not  enter,  he  fails  in  his  bounden 
duty  and  his  profession  will  suffer  in  honor  and  other 
emoluments. 

When  we  read  the  morning  papers  we  are  struck 
with  the  unvarying  succession  of  delinquencies  all  the 
way  from  crimes  against  person  to  crimes  against 
property  that  are  committed  under  such  conditions  as 
mark  the  perpetrator  indubitably  mad.  Many  of  these 
delinquencies  are  the  first  symptoms  of  adolescent  in- 
sanity, others  are  the  oft-repeated  obsessions  of  the 
old  stager.  The  former  are  recognized  by  the  alienist 
as  the  beginning  of  a  degenerative  disease;  the  latter 
are  known  to  the  local  police  as  the  work  of  well- 
known  crooks.  The  great  flood  of  delinquencies  which 
furnishes  the  ostensible  occupation  of  the  police  is  the 
product  of  the  mind  diseased. 

We  are  reminded  of  the  fact  that  not  so  long  ago  all 
insane  people  were  punished.  Now  some  are  confined, 
some  cared  for,  some  studied  and  some  cured.  Un- 
fortunately for  us  physicians,  and,  possibly,  unfortu- 
nately for  the  insane  themselves,  they  are  segregated 
and  removed  from  all  possibility  of  our  observation. 
We,  two  or  three  of  us,  report  our  opinions  to  a  judge, 

7 


8  ESSAYS. 

he  commits  our  patient  to  a  madhouse,  a  lunatic  asy- 
lum, an  asylum  for  the  insane,  a  hospital  for  the  in- 
sane or  a  State  hospital  (the  nomenclature  depending 
upon  the  stage  of  legislative  fastidiousness),  and  that 
is  the  last  time  we  see  him.  He  falls  under  the  care 
of  a  class  of  medical  men  who  are  so  far  removed  from 
the  general  and  common  profession  that  they  are  as 
strange  and  spooky  to  us  as  judges  and  lawyers  them- 
selves. In  our  medical  schools  as  students  and  in  our 
hospital  service,  the  insane  are  no  longer  under  our 
observation  and  care.  The  physicians  who  are  in  in- 
stitutions are  too  busy  in  routine  work  to  attend  our 
medical  societies,  and  in  some  benighted  States,  legis- 
lative enactment  makes  it  impossible  for  medical  socie- 
ties and  clinics  to  be  held  in  the  asylums.  By  the  very 
necessities  of  the  case,  the  insane  are  in  the  care  of  a 
very  small  portion  of  the  profession — salaried  men, 
who  do  not  think  as  we  do,  try  as  hard  as  they  may. 

The  most  opinionated  of  us  is  forced  to  admit  that 
the  great  bulk  of  adolescent  delinquents  are  more  in 
need  of  a  doctor  than  of  a  judge.  A  large  portion  of  the 
army  of  hobos  that  besiege  every  large  town  and  city 
are  "on  the  road"  because  they  are  sick.  They  are 
smoking  opium  or  taking  cocaine  because  the  equilib- 
rium of  their  nervous  systems  is  disturbed.  Disease 
makes  the  tramp  and  mental  disease  the  delinquent. 
"Over  half  of  the  murderers,"  said  Dr.  Allison,  of  the 
Matteawan  Hospital  for  the  Criminal  Insane,  "were 
received  from  prisons  to  which  they  had  been  com- 
mitted for  life.  At  least  40  per  cent,  of  these  were 
obviously  insane  at  the  time  of  their  conviction.  In 


PUNISHMENT  OR  CURE.  9 

many  instances  no  plea  of  insanity  was  put  up  by  their 
attorneys ;  in  others,  this  plea  was  overruled." 

In  the  Province  of  Quebec,  699  insane  persons  were 
condemned  to  prison  during  seventeen  years  (1881- 
1897),  an  average  of  40  a  year.  In  one  year  alone, 
1892,  Paris  sent  255  persons  to  prison  who  were  after- 
ward declared  insane  and  removed  from  prisons  to 
hospitals.  In  the  Massachusetts  Asylum  for  Insane 
Criminals,  out  of  400  men,  216  were  irresponsibly  in- 
sane at  the  time  they  were  tried,  corivicted  and  con- 
demned to  penal  institutions.  Only  40  of  them  were 
recognized  as  insane. 

Just  how  large  a  per  cent,  of  the  crimes  against 
person  are  committed  by  the  insane  it  is  not  possible 
to  say.  The  opinion  of  competent  observers  is  at  one 
that  it  is  very  large;  and  from  time  to  time,  at  least 
from  decade  to  decade,  the  estimate  of  those  observers 
gradually  rises.  Crimes  against  property  are  of  a 
considerably  different  nature.  They  vary  much  accord- 
ing to  the  location  of  the  bread  line  and  the  magnitude 
of  other  economic  and  social  factors.  But  even  here  a 
growing  portion  of  the  delinquents  are  found  to  be 
insane. 

This  is  not  the  place  to  criticise  the  administration 
of  justice  in  our  criminal  courts ;  it  is,  however,  the 
place  to  demand  that  the  insane  man  whose  disease  is 
first  discovered  by  a  delinquency — a  crime  against 
person  or  a  crime  against  property — be  promptly, 
safely  and  decently  put  in  the  proper  surroundings  for 
diagnosis  or  cure.  We  understand  that  an  insane  man 
may  be  as  responsible  for  a  criminal  act  as  a  sane  man, 


10  ESSAYS. 

but  even  when  that  is  the  case  his  punishment  should 
not  take  precedence  over  his  cure.  His  apprehension, 
his  examination,  his  trial  and  his  conviction  should  be 
guided  and  even  stayed  by  the  indications  for  the  treat- 
ment of  his  disease.  The  public  mind  may  be  mo- 
mentarily outraged  by  a  terrible  crime,  but  public  re- 
morse at  the  deliberate  revenge  of  courts,  that  should 
be  courts  of  justice  if  not  of  mercy,  is  not  soon  for- 
gotten. Note,  for  example,  the  vengeance  meted  out 
to  the  insane  murderers  of  Lincoln,  Garfield  and  Mc- 
Kinley  and  the  apologies  with  which  those  dark  pages 
of  our  national  history  are  now  written,  read  and 
taught  to  our  children. 

The  public,  when  informed,  will  not  permit  the  pun- 
ishment of  the  insane  delinquent,  be  he,  in  the  opinion 
of  the  court,  responsible  or  irresponsible  for  his  crime. 
If  the  convict  has  pneumonia  he  is  placed  at  once  under 
the  care  of  a  physician  and  nurse.  Insanity  is  a  dis- 
ease more  serious  than  any  of  the  acute  infections.  If 
the  convict  is  insane  he  should  be  in  the  hospital  for 
the  insane. 

It  is  only  a  step  further  to  say  that  the  suspect  who 
is  not  yet  tried  and  convicted  should  have  as  much 
justice,  mercy  and  decency  shown  him  as  the  convict 
receives.  We  do  not  wait  until  after  the  trial  to  re- 
move the  typhoid  to  the  hospital ;  we  stop  the  trial 
until  the  patient  is  recovered  of  typhoid.  There  may 
be  no  statute  and  no  law  to  such  effect,  but  it  is  a 
matter  of  judicial  decency  in  every  civilized  commu- 
nity. Does  it  need  a  law  to  put  the  insane  suspect  in 
the  same  position  and  stay  his  trial  until  he  recovers 


PUNISHMENT  OR  CURE.  11 

of  his  insanity  ?  In  Vermont  it  did,  and  a  hospital  was 
provided  in  which  every  delinquent  was  placed  for  the 
determination  of  his  mental  condition.  The  law-made 
machine  did  not  work  true  every  time,  but  it  did  pre- 
vent several  most  disgraceful  and  expensive  trials,  and 
robbed  no  one  except  only  the  clique  of  professional 
alienists  who  hang  around  the  honey  pot  of  the  crim- 
inal court. 

There  is  one  place  in  which  the  insane  delinquent  is 
wholly  unprotected,  and  that  is  in  the  hands  of  the 
police.  One  may  always  be  afraid  of  being  called  an 
anarchist  when  he  criticises  the  police.  We  hold,  how- 
ever, that  the  police  have  no  license  to  be  more  brutal 
or  less  gentlemanly  and  dignified  toward  the  arrested 
one  than  the  judge  on  the  bench  or  the  private  citizen 
in  his  office  or  shop.  The  torture  is  illegal.  If  all  the 
suspects  were  sane,  we  should  have  no  reason  to  place 
our  protest  as  medical  men  in  these  columns.  We  have 
objected  more  or  less  successfully  to  the  ancient  custom 
of  the  police  locking  up  until  the  next  morning  the  man 
with  the  fracture  of  the  vault  just  to  sober  him  off. 
Now  again  we  protest  against  torturing  the  arrested 
man  to  get  a  confession  of  the  crime  for  which  he  was 
arrested.  The  water  treatment,  the  third  degree,  the 
sweat  box  and  the  inquisitional  methods  regularly  em- 
ployed by  the  metropolitan  police  and  their  rural  imi- 
tators may  be  endured  by  the  sane ;  but  they  are  cruel, 
beyond  the  cruelty  of  burning  witches,  to  the  insane. 
To  quote  from  to-day's  paper  (Chicago  Tribune,  June 
22,  1909)  just  a  few  lines,  which  can  be  duplicated 


12  ESSAYS. 

almost  any  day,  is  proof  enough  that  the  way  to  justice 
is  cruel : 

"The  little  Chinaman,  his  eyes  bloodshot  from  ex- 
haustion and  lost  sleep,  was  planted  in  a  big  chair, 
while  a  big  captain  of  detectives  and  an  assistant  dis- 
trict attorney  stood  in  front  of  him  driving  their  ques- 
tions home. 

"You  could  hear  the  roar  of  the  captain's  voice  as  he 
bellowed  some  emphatic  charge,  the  quieter  monotone 
of  the  district  attorney  as  he  prodded  the  Chinaman 
persistently,  determinedly,  and  the  falsetto  squeak  of 
Chung  Sing  when  they  stung  him,  as  they  did  every 
now  and  then,  to  hysterical  rage.  .  .  Chung  Sing  had 
been  against  the  police  grindstone  all  day,  but  you 
couldn't  have  told  it  to  look  at  him  except  maybe  for 
his  red  eyes  and  the  nervousness  that  showed  despite 
his  wooden  pose.  Police  official  after  police  official 
had  been  pecking  at  him  all  day  since  6  o'clock  in  the 
morning,  when  he  was  brought  down  from  Amsterdam, 
where  he  had  been  caught  on  Monday. 

"It  was  not  permitted  to  Chung  Sing  to  sleep  on 
Monday  night.  As  soon  as  the  lieutenant  got  the 
Chinese  away  from  the  chief  at  Amsterdam  he  began 
to  shoot  questions  at  him.  He  grill-ed  him  while  they 
waited  for  the  train,  while  they  made  the  long  ride  to 
this  city,  while  they  were  on  their  way  to  police  head- 
quarters, and  where  he  left  off  the  captain  took  it  up. 
For  twenty-four  hours  they  racked  him  with  questions, 
getting  a  little  here  and  a  little  there." 

There  is  a  radical  defect  in  our  criminal  practice 
when  it  fails  to  take  cognizance  of  the  fact  that  more 
than  one- fourth,  if  not  more  than  one-half,  of  all  de- 
linquencies against  persons  are  perpetrated  by  insane 
culprits.  In  a  large  per  cent,  of  all  cases  the  evidence 


PUNISHMENT  OR  CURE.  13 

of  insanity  can  be  discovered  only  by  such  observation 
as  the  law  of  Vermont  provides.1  The  courts  are  ex- 
pensive. If  they  fail  to  meet  their  end  on  account  of 
faulty  methods  their  methods  should  be  changed.  If 
their  methods  are  working  to  the  injury  of  the  sick  it 
is  the  duty  of  our  profession  to  make  these  injuries 
manifest  to  the  public  to  the  end  that  they  demand 
correction.  In  matters  of  this  kind  public  sentiment, 
like  the  judgment  of  posterity,  is  infallible  and  inex- 
orable. It  remains  for  us  who  know  to  do  away  with 
the  disgraceful  spectacle  of  expert  testimony  for  and 
against  the  defendant,  to  abolish  police  prisons  in  the 
hands  and  control  of  the  police,  to  make  the  tortures 
of  the  police  and  prosecuting  attorneys  as  execrable  to 
the  leaders  of  our  enlightened  press  as  are  the  atrocities 
of  the  Turk  and  the  tortures  of  the  Spanish  Inquisi- 
tion.2 

1  Public  Statutes  of  Vermont,  1906,  Sec.  6084,  p.  1170. 

2  Torture  by  Indian  Police.    The  Nation,  London,  vol.  viii, 
p.  1038. 


THE  INHUMAN  METHOD  OF  COMMITMENT 
OF  THE  INSANE. 


IN  THE  State  of  Illinois  the  insane  are  committed 
by  a  jury  trial  or  by  commission.  In  the  city  of  Chi- 
cago the  court  is  held  once  a  week  at  the  detention 
hospital,  in  a  room  about  20x30  feet  on  the  floor,  di- 
vided by  railings  into  three  portions.  Doors  open  into 
the  hospital  ( ?)  which  is  under  the  charge  of  a  physi- 
cian, who  brings  the  patient  and  his  history  into  court 
and  gives  his  opinion  and  diagnosis.  The  jury  or  each 
jury,  as  there  are  usually  two,  consists  of  one  physician 
and  five  other  men.  A  jury  hears  four  cases  and  then 
retires  and  the  other  jury  comes  on  and  hears  the  next 
four  cases.  The  duty  of  the  jury  seems  to  be  to  obey 
the  dictates  of  the  judge,  and  he  may  overrule  their 
findings  or  that  of  a  commission.  The  judge  is  a 
circuit  judge,  so-called;  the  one  on  duty  at  the  time 
referred  to  in  this  article,  was  from  the  country,  i.e., 
outside  of  Cook  County.  He  did  not  seem  to  be  es- 
pecially expert  as  an  alienist. 

There  were  more  than  forty  cases  called  for  nine 
o'clock  on  the  Thursday  morning  here  described. 
They  were  all  disposed  of  by  the  two  aforementioned 
juries.  An  army  of  witnesses  were  called,  all  of  them 
at  9  o'clock,  and  they  seemed  to  be  on  hand,  filling 
waiting-rooms,  stairways,  halls  and  every  approach  to 
the  diminutive  courtroom.  All  the  cases  were  disposed 
of  before  noon,  except  one  which  was  contested. 

The  witnesses  were  brought  in  sometimes  with  and 
15 


16  ESSAYS. 

sometimes  without  the  patient,  or  accused,  which  shall 
we  say?  They  were  let  inside  the  rail  together  and 
sworn.  Then  the  examination  began  with  the  report 
of  the  physician  of  the  detention  hospital,  and  was 
conducted  in  a  haphazard  manner  by  attorneys,  jurors, 
and  the  judge.  Everybody  was  declared  insane  except 
one  woman  that  every  witness  testified  was,  in  his 
opinion,  crazy  and  that  every  juror  apparently  believed 
was  irresponsible.  Xot  all  were  committed,  however. 
Something  more  than  one-fourth  of  these  unfortu- 
nates were  taken  home  by  friends.  They  were  not  the 
chronics,  but  the  acute  cases  that  ought  to  be  amenable 
to  hospital  treatment  now  if  ever.  The  anxiety  and 
devotion  of  the  friends  of  the  insane  was  a  most  heart- 
warming, if  heart-breaking,  spectacle.  Their  affection, 
however,  did  not  always  guide  them  aright.  The  fear 
of  institutions,  which  is  not  entirely  unfounded,  led 
them  wrong.  The  judge  assessed  the  friends  ten  to 
twenty-five  dollars  for  each  committed  patient  for  the 
expenses  of  commitment  and  transportation  to  one  of 
three  asylums  within  a  radius  of  fifty  miles.  The 
whole  proceeding  was  more  terrible  than  the  infamous 
Monday  grind  at  the  Harrison  Street  police  court. 
Officers  whose  duties  require  their  attendance  on  this 
court  are  apt  to  get  drunk  on  Thursday  afternoon ! 

It  is  our  contention  that  such  a  method  of  commit- 
ment is  irrational,  ineffectual  and  unmerciful.  It  is 
dangerous,  extravagant,  demoralizing  and  cruel.  It  is 
law  run  mad  with  the  sick,  it  is  ignorance  and  red  tape 
in  an  emergency.  It  is  an  irreparable  injury  to  many 
of  the  insane,  an  unnecessary  and  unusual  punishment 


1XHUMAN  METHOD  OF  COMMJTMEXT.         17 

to  the  friends  of  the  insane,  and  a  stinking,  rotten  sore 
on  our  civilization. 

Even  the  execution  of  the  present  law  is  unneces- 
sarily cruel.  All  the  cases  are  called  for  nine  in  the 
morning.  Call  it  ten.  The  witnesses,  often  neighbors 
or  physicians,  are  obliged  to  remain  willy-nilly  until 
twelve  or  one  o'clock  with  no  place  to  wait  in.  This 
is  unnecessary  cruelty  to  them.  The  presence  of  the 
patient  is  indispensable. 

It  was  pitiable  to  see  the  helplessness  of  the  friends 
of  the  insane.  They  were  overcome  by  the  terrible 
and  inconceivable  misfortune  which  had  befallen  them. 
They  had  no  precedent  on  which  to  depend.  They  had 
never  been  in  court  before  and  had  looked  upon  judges 
as  those  who  condemn  and  sentence  to  punishment. 
The  surroundings  were  all  cold  and  unsympathetic,  not 
even  what  you  might  etymologically  expect,  courteous 
and  civil. 

The  courts  assume  to  guard  personal  liberty  by  the 
force  and  graft  of  a  jury  trial.  The  constitutional 
rights  of  personal  liberty  makes  the  law  which  allows 
of  commitment  by  commission  inoperative  in  Cook 
County,  where  the  judges  are  so  jealous  of  personal 
liberty.  More  than  ten  thousand  commitments  have  been 
made  in  Cook  County  without  a  single  appeal  from 
the  orders  of  the  court,  until  the  other  day  a  perfectly 
safe  and  self-supporting  but  committed  paranoiac, 
acting  as  his  own  attorney,  convinced  the  court  after 
reading  a  lucid  plea  that  he  was  entitled  to  an  appeal, 
showed  the  form  and  destination  of  his  bond  to  an 
astounded  judge  and  got  his  legal  privilege  allowed. 


18  ESSAYS. 

Illinois  still  remains  in  the  background  in  all  matters 
relating  to  the  treatment  of  her  wards.  Her  epileptics 
are  at  large,  her  police  are  hounding  the  delinquents 
who  have  not  yet  shown  the  unmistakable  evidences 
of  insanity ;  and  while  millions  are  spent  in  penal  insti- 
tutions and  in  custody,  not  a  dollar  is  appropriated  for 
the  prevention  of  either  insanity  or  crime.  The  sick 
who  need  hospital  treatment  or  segregation  must  be 
brought  to  an  uncourteous  and  merciless  tribunal, 
which  sits  only  on  Thursday  morning,  to  be  allowed  a 
chance  to  the  none  too  liberal  therapeutics  of  the  State 
hospitals  for  the  insane.  The  jury  is  an  asinine  form, 
the  presence  of  the  sick  person  in  court  is  unmerciful 
and  cruel,  the  long  hours  of  attendance  of  witnesses  is 
barbarous  and  despotic,  and  the  selection  of  such 
merciless  legal  forms  for  the  more  humane  commission 
provided  by  statute  is  a  judicial  tyranny  which  ill  be- 
comes a  democratic  State.  Until  the  organization  of 
the  friends  of  the  insane  can  make  their  influence  felt 
such  atrocities  are  likely  to  be  committed  in  the  name 
of  liberty. 


FINDING  A  WAY  OUT  FOR  THE  LOST  MIND. 


IN  A  recent  lecture  before  a  meeting  of  educated  club 
women  a  newspaper  reporteress  spent  the  hour  in  a 
literary  conversation  on  Charles  Lamb.  The  signifi- 
cance of  the  lecture  to  us  lies  in  the  attitude  of  the 
speaker  and  presumably  of  a  majority  of  the  audience 
toward  the  mental  condition  of  the  unfortunate  Mary 
Lamb.  More  than  half  the  hour  was  devoted  to  the 
mysticism  with  which  her  conduct  was  dressed.  The 
sacrifice  which  Charles  Lamb  made  was  criticised  in 
the  light  of  crass  utilitarianism. 

There  still  remain  in  the  minds  of  the  educated 
about  the  same  attitude  toward  the  insane  that  our 
ecclesiastical  New  England  ancestors  manifested 
toward  the  witches.  The  sister  of  Charles  Lamb 
might  have  had  any  other  disease  without  arousing 
among  literary  critics  more  than  a  sympathetic 
mention.  Had  she  been  blind  and  mute  no  one  would 
have  questioned  the  propriety  of  an  equal  devotion  or 
criticised  adversely  the  sacrifice  which  her  brother 
made  for  her  comfort  and  happiness.  The  senti- 
mentalists of  to-day  have  no  trouble  in  getting  special 
legislative  appropriations  for  the  Helen  Kellers  of 
each  State.  In  romantic  literature  and  in  ordinary 
gossip  the  etiology  and  manifestations  of  insanity  are 
portrayed  and  exposed  in  a  dim  and  sulphurous  light 
and  surrounded  with  grizzly  mystery.  Even  the 
guardians  of  the  insane  have  been  known  to  shudder 
and  cry  "Birr!  Birr!"  at  the  sight  of  a  hundred  or 

19 


20  ESSAYS. 

more  unfortunate  dements  huddled  in  a  gymnasium- 
like  dormitory. 

The  modern  literary  mind  still  holds  to  the  tra- 
ditional. Our  current  novelists,  having  exhausted 
their  ingenuity  with  normal  human  passion,  introduce 
among  their  relatively  and  conventionally  sane  charac- 
ters the  problematically  or  obviously  insane.  In  two 
of  our  most  dignified  monthlies  appeared  during  a 
single  month  novelettes  in  which  one  of  the  characters 
was  insane.  A  year  or  so  ago  one  of  the  magazines 
ran  a  long  serial  the  hero  of  which  was  crazy  and  his 
sister  feeble-minded.  The  cloak  of  mysticism  and  the 
inexorable  clouds  of  heredity  were  thrown  around  the 
pathological  psychology  of  the  characters  which  the 
imagination  of  the.  authors  built  up.  The  theory  of  a 
diabolical  origin  of  insanity,  which  arose  from  ecclesi- 
astical prejudice,  has  given  way  as  an  adequate  cause 
for  mental  aberration ;  and  heredity,  the  scientific 
bogey-man,  rules  the  stage. 

Of  course,  the  thoughtful  physician  knows,  and  has 
known  for  half  a  century,  that  insanity  is  a  symptom 
of  many  diseases,  just  as  anemia  is.  He  has  seen  one 
form  of  anemia  after  another  pass  from  the  mysterious 
into  the  commonplace.  The  still  unknown  anemias 
which  masquerade  as  "pernicious  anemia,"  "leukemia" 
and  "pseudo-leukemia"  are  no  longer  looked  upon  as 
dispensations  from  heaven  or  hell,  but  as  inevitable 
results  of  adequate  though  unknown  causes.  Our 
knowledge  of  the  hookworm  disease,  kala-azar  and  the 
trypanosome  have  taken  away  three  territories  from 
this  unknown  country  of  anemia  and  also  opened  up 


FIXDIXG  A  WAY  OUT.  21 

new  methods  of  study  which  have  been  neglected  since 
the  discovery  of  the  hookworm  seventy  years  ago. 
The  same  conquests  may  be  hoped  for  in  the  region  of 
the  insanities.  The  physician  does  not  take  kindly  to 
the  idea  that  insanity  is  a  perversion  of  reason,  a  sort 
of  Christian  Science  idea  transferred  to  a  narrow  field 
of  medicine.  He  knows  that  the  aged  are  insane  and 
demented  because  the  machinery  of  nutrition,  excre- 
tion and  physiologic  resistance  is  used  up.  He  believes 
that  general  paresis  conies  upon  the  syphilitic  be- 
cause syphilis  has  reduced  the  resistance  of  his  body  to 
some  ever-present  organism  that  thus  succeeds  in  in- 
vading his  protective  mucosa  and  his  cerebro-spinal 
lymph  ways.  He  believes  that  the  alcoholic  and  the 
dope-fiend  becomes  looney  because  the  drug  has  both 
poisoned  them  and  diminished  their  normal  resistance 
to  invasion  by  micro-organisms  that  further  intoxicate 
them.  He  knows  that  the  insanities  of  hyperthyroid- 
ism  and  myxedema  are  two  forms  of  so-called  auto- 
genous toxemia,  and  so  on  to  the  end.  There  is  no 
form  of  insanity  which  the  physician  is  willing  to  con- 
sider a  dispensation  from  heaven  or  a  witchery  from 
below,  and,  therefore,  in  either  case,  hopeless  of  cure 
and  prevention  and  beyond  scientific  investigation  and 
explanation. 

Let  us  review  the  progress  of  a  lev/  indubitable  ex- 
tensions of  the  boundary  of  our  knowledge  of  anemia 
for  a  first  lesson. 

The  hookworm  was  discovered  in  1838,  but  more 
than  sixty  years  afterwards  Ash  ford  demonstrated  that 
it  was  the  cause  of  the  larger  part  of  the  morbidity  and 


22  ESSAYS. 

mortality  in  Porto  Rico.  Only  during  the  last  ten 
years  and  largely  through  the  work  of  the  Agricul- 
tural Department,  has  the  extent  and  importance  of 
this  parasite  in  the  United  States  been  recognized  by 
the  profession  and  the  public  at  large.  Clyde  Smith, 
of  Atlanta,  demonstrated  the  origin  of  ground  itch  and 
the  possibility  that  the  hookworm  gains  access  to  the 
body  through  the  skin.  This  placed  the  discredited 
observation  of  Loos  in  its  proper  place,  and  made  it 
evident  that  the  ground  itch  was  in  a  considerable 
number  of  cases  the  beginning  of  the  hookworm  dis- 
ease. 

Another  instance  which  has  not  been  so  well  recog- 
nized because  the  disease  is  not  known  to  exist  in 
America  is  the  so-called  black  water  fever,  or  kala-azar, 
of  Assam.  Since  1882  this  disease  has  decimated  the 
population  of  an  area  larger  than  Texas.  When  it  has 
passed  over  a  country  it  subsides,  leaving  frequently 
less  than  one-ninth  of  the  population  alive.  The  dis- 
ease was  long  known  as  malarial  cachexia,  and  only 
during  the  last  ten  years  has  the  essential  etiologic 
factor  been  proven  to  be  a  flagellated  piroplasma.  an 
obligate  parasite  of  some  such  animal  as  the  bedbug. 
This  micro-organism  is  known  as  Donovan's  body. 
The  disease  which  it  produces  resembles  typhoid  and 
malaria  in  so  many  particulars  that  a  clinical  diagnosis 
can  be  made  only  by  long  observation  or  by  the  most 
exacting  microscopical  and  biological  tests.  The  leuco- 
penia,  the  absence  of  the  malarial  organism  and  the 
Widal  reaction,  however,  makes  an  early  relative  diag- 
nosis possible.  Isolation,  segregation  and  the  extcr- 


FINDING  A  WAY  OUT.  23 

ruination  of  bedbugs  secures  safety  to  the  unaffected 
and  arrests  the  epidemic.  Dodds  Price  was  able  to 
keep  coolies  in  perfect  health  in  new  shacks,  though 
only  two  hundred  feet  away  from  quarters  in  which 
cases  of  kala-azar  were  appearing  and  dying  every  day. 
He  saved  the  English  tea  gardens  of  Assam  by  first 
killing  the  bedbugs  in  the  old  shacks,  segregating  the 
coolies  that  were  already  sick  and  securing  absolute 
freedom  of  shacks  and  coolies  from  vermin.  Kala-azar 
has  also  been  recognized  in  Burmah,  and  there  is 
reason  to  fear  that  it  will  sooner  or  later  be  found  in 
the  Philippines,  in  Australia,  and,  possibly,  the  south- 
ern United  States. 

Mountain  fever  or  tick  fever  is  almost  perfectly 
illuminated  by  the  work  of  Ricketts.  It  remains  only 
to  apply  our  knowledge  to  prevent  this  disease. 

The  conquest  of  yellow  fever  is  so  recent  and  the 
tragic  and  irrefutable  demonstration  of  its  cause  and 
prevention  are  so  popularly  known  that  it  needs  only 
to  be  mentioned.  The  dark  speculations  that  once 
surrounded  the  etiology  of  this  disease  are  in  the  for- 
gotten literature  of  medicine. 

The  hookworm  disease  affected  a  million  or  more, 
the  sleeping  sickness  has  depopulated  Africa,  the 
Donovan  body  of  kala-azar  has  nearly  ruined  the  prov- 
ince of  Assam,  the  yellow  fever  germ  and  mosquito 
has  killed  its  millions  and  set  back  the  civilization  of 
half  a  continent  three  hundred  years. 

But  what  does  all  this  mean?  We  have  established 
a  Sleeping  Sickness  Commission,  a  Wellcome  Labora- 
tory, a  School  of  Tropical  Diseases,  and  fearlessly  in- 


24  ESSAYS. 

vaded  the  tropics  to  take  the  moat  out  of  our  neigh- 
bor's eye,  while  150.000  insane  are  segregated  in  the 
custody  of  our  madhouses  and  no  adequate  effort  is 
made  to  study  the  causes  of  insanity.  The  Phipps  en- 
dowment at  Johns  Hopkins,  the  Laboratory  of  the 
London  County  Council  and  the  fitfully  supported 
Psychopathic  Institutes  of  New  York,  Michigan  and 
Massachusetts  are  overcome  by  the  magnitude  of  the 
problem  before  them. 

Insanity  is  one  symptom  of  many  diseases.  In  the 
very  old,  insanity  is  a  terminal  symptom,  and  the  senile 
make  up  nearly  10  per  cent,  of  all  admissions.  The 
adolescent  insanities  are  the  most  pitiable  and  most 
hopeless.  They  furnish  about  40  per  cent,  of  all  ad- 
missions, and  only  3  or  4  per  cent,  recover.  The  manic- 
depressive  group  claim  about  half  the  admissions,  and 
furnish  the  largest  per  cent,  of  recoveries.  About  20 
per  cent,  of  these  recover. 

The  attitude  of  the  leaders  of  the  institutions  for 
the  custody  of  the  insane  toward  the  study  of  the  eti- 
ology of  insanity  is  illustrated  by  the  proceedings  of 
the  national  societies  and  publications  of  psychiatry. 
The  proceedings  of  the  American  Medico-Psychologi- 
cal Association  (497  members)  for  the  1909  meeting 
contains  590  pages  and  thirty  different  contributors. 
Only  three  of  these  contributors  (namely,  Stanley,  "A 
Report  of  Three  Cases  of  Korsakow's  Psychosis ;" 
May,  "A  Review  of  Recent  Studies  of  General  Par- 
esis;" Moore,  "Application  of  Immunity  Reaction  to 
the  Cerebro-Spinal  Fluid")  discuss  scientific  physical 
problems. 


FINDING  A  WAY  OUT.  25 

In  regard  to  the  attitude  of  the  society  toward  the 
investigation  of  the  physical  condition  of  the  insane, 
the  lack  of  discussion  is  most  significant.  It  would 
appear  that  stenographic  notes  of  the  discussions  were 
not  always  made,  or  if  made  were  not  used,  so  that 
many  omissions  are  evident.  Still  it  is  evident  that 
there  is  the  greatest  pessimism  regarding  the  causative 
relation  of  any  physical  condition,  even  exophthalmic 
goiter,  to  insanity.  A  few,  however,  cast  discredit  upon 
heredity,  and  made  it  a  waning  factor  in  the  produc- 
tion of  mental  aberration.  The  most  authoritative 
alienists  are  against  the  whole  idea  of  a  physical  basis 
for  the  etiology  of  insanities.  Note,  for  instance,  the 
unchallenged  conclusion  of  Campbell  on  pp.  412-413, 
loc.  cit. 

Turn  the  pages  of  any  or  all  of  the  journals  of 
psychiatry  and  insanity,  and  the  conclusion  will  be 
forced  upon  you  that  the  alienists  are  not  doctors. 
They  are  keepers  of  the  insane.  Many  of  them  are 
good  lawyers,  many  are  good  administrators,  all  of 
them  are  good  politicians  and  men  of  superior  intel- 
lects, but  they  seem  to  be  outside  of  pure  science  and 
of  practical  medicine.  Nothing,  in  my  opinion,  can  be 
expected  from  the  present  rank  and  file  of  the  keepers 
of  the  insane  in  investigating  its  etiology. 

One  of  the  first  things  to  do  in  approaching  the  prob- 
lem before  us  is  to  separate  the  conditions  precedent 
to  the  insanity  from  the  conditions  incident  to  the  cus- 
tody. The  intensive  study  of  tuberculosis  has  put  this 
complication  in  its  proper  place — it  is  the  result  of  the 
institutionalizing,  poor  feeding,  overcrowding,  over- 


26  ESSAYS. 

heating,  indoor  confinement.  The  happy  appearance  of 
pellagra  in  nearly  every  institution  for  the  insane  ought 
to  change  the  dietary  from  the  unknown  and  neglected 
to  the  show-room  of  the  madhouse.  Tuberculosis  and 
pellagra  are  bred  by  starvation  or  inadequate  and  im- 
proper diet.  Pellagra  is  at  once  the  cause  of  one  in- 
sanity and  the  result  of  the  cut  and  dried  institutional 
life  of  the  insane  asylums. 

In  the  surgical  hospitals  of  our  ancestors  (before 
1870)  certain  wound  diseases  were  endemic.  Every 
fresh  lacerated  wound  was  planted  with  pus  microbes, 
with  erysipelas  cocci  or  with  the  bacillus  of  malignant 
edema  before  the  patient  had  been  in  the  hospital  a 
week.  The  attitude  of  the  surgeons  of  the  time  (Lar- 
rey,  "Observations  on  Wound  Diseases,"  Philadelphia, 
1832)  is  remarkably  parallel  with  the  attitude  of  the 
custodians  of  the  insane  to-day.  It  was  the  pure  sci- 
entist, Pasteur,  and  a  deluded  surgeon,  Lister,  that  at 
last  eliminated  the  dangers  of  hospitalism  from  wound 
treatment,  and  made  remedial  and  elective  surgery 
take  the  place  of  terminal  surgery. 

The  interested  public  must  put  away  the  idea  that 
the  insanities  are  without  adequate  tangible  physical 
cause,  and  the  subject  must  no  longer  be  taboo  in  sci- 
entific, medical  and  social  conversation.  It  is  far  less 
disgraceful  to  the  individual,  to  the  family  and  to  the 
community  to  have  a  case  of  insanity  appear  in  it  than 
to  have  a  case  of  typhoid.  The  origin  of  the  former 
is  unknown  and  hence  unpreventable ;  the  source  of 
the  latter  is  positively  demonstrated  and  its  presence 
inexcusable. 


FINDING  A  WAY  OUT.  27 

The  insanities,  so  far  as  their  etiology  is  known  at 
all,  are  toxemias,  and  the  sort  of  toxins  and  the  pos- 
sibility of  their  prevention  and  elimination  await  ad- 
vances in  chemical  dietary  and  perhaps  physical  sci- 
ence, or  the  application  of  neglected  facts  long  avail- 
able. 

The  present  custodians  of  the  insane  have  no  sym- 
pathy with  and  no  incentive  for  the  study  of  the  causes, 
cure  or  prevention  of  the  insanities,  and  the  insane 
asylum  to-day  is  a  chilly  place  for  scientific  study  of 
any  sort  or  kind.  Even  in  some  of  the  "psychopathic 
wards"  the  routine  investigations  remind  one  rather 
of  the  sacerdotal  confessional  of  some  strange  cult,  or 
of  the  seances  of  the  votaries  of  a  complicated  system 
of  planchettes  than  of  a  scientific  investigation. 

The  vis  a  tergo  of  any  adequate  study  of  the  condi- 
tion of  the  helpless  insane  must  come  from  their 
friends  still  unconfined.  Their  influence  should  be 
used  in  every  possible  direction ;  first,  upon  the  schools 
of  pure  science  by  the  establishment  of  scholarships 
and  prizes ;  second,  upon  legislators  to  devote  a  tithe 
of  all  appropriations  for  custody  to  a  study  of  etiology, 
prevention  and  cure;  and  lastly,  to  point  out  to  the 
generous  millionaire  a  most  hopeful  field  of  scientific 
adventure. 


THE  PHYSICAL  BASIS  OF  DEMENTIA 
PRECOX.1 


As  LONG  as  the  pathogenesis  of  a  disease  is  unsought 
and  unknown,  no  rational  treatment  or  prevention  can 
be  looked  for.  The  fact  that  the  senile,  syphilitic  and 
alcoholic  insane  are  in  a  relatively  hopeless  condition, 
on  account  of  the  essential  elements  of  these  condi- 
tions, makes  their  care  largely  custodial.  If  any  group 
of  the  insane  need  study  and  promise  possibilities  of 
cure,  it  is  the  dementia  precox  group.  The  profes- 
sional keepers  of  the  insane,  however,  make  no  studies 
of  the  physical  conditions  of  these  unfortunate  youths. 
They  are  weighed  and  measured  when  they  enter  the 
asylums  as  the  rules  usually  prescribe.  Sometimes 
other  clinical  examinations  are  made,  and  even  the  Ber- 
tillon  identification  system  is  applied  in  all  its  perfec- 
tion. The  further  study  of  the  cases  is  unprovided 
for.  There  are  no  laboratories  where  any  borderland 
examinations  can  be  made,  were  there  any  students  in 
interne  service  capable  of  physiological  and  chemical 
analyses.  One  State  superintendent,  whom  the  writer 
consulted,  spoke  of  his  disheartening  efforts  in  study- 
ing the  toxicity  of  the  blood  in  certain  cases.  He  was 
short  on  equipment,  on  animals,  on  cages,  on  men,  and 
inexorably  obstructed  by  custom,  financial  limitations 

1  This  clinical  term  is  applied  by  many  modern  psychiatrists 
to  a  mixed  group,  mostly  adolescents,  who  show  a  tendency 
to  a  peculiar  course  toward  dementia. 

29 


30  ESSAYS. 

and  political  interference.  Even  the  civil  service  rules 
prevented  his  securing  a  capable  investigator. 

The  complacency  and  stoical  inactivity  of  the  great 
mass  of  the  professional  custodians  of  the  insane  are 
impregnable.  They  have  all  the  patients.  They  are 
under  no  obligation  to  cure  anybody.  The  institution 
is  everything;  the  patients  are  simply  inmates  to  be 
kept  until  they  go  or  are  taken.  Any  attempt  at  cure 
is  outside  the  esprit  dc  corps  of  these  intellectual  pes- 
simists and  emotional  nihilists.  Such  a  proposition  as 
a  cure  is  received  with  the  same  air  as  one  of  the  illu- 
sionary  vagaries  of  a  deluded  patient.  One  soon  falls 
down  before  such  resistance  when  he  has  to  meet  all 
the  other  discouragements  of  a  pioneer.  But  these 
studies  must  be  made  in  custodial  State  institutions. 
They  must  be  made  by  men  whose  motives  spring  from 
the  heart.  Our  only  hope  is  in  votaries  to  humanity 
rather  than  in  savants  of  science.  The  problem  re- 
quires team  work  between  clinicians,  pathologists, 
chemists  and  physiologic  chemists.  It  must  be  done 
with  all  the  resources  of  a  university — laboratories,  li- 
braries and  the  broadest  knowledge  of  pure  science. 

It  should  be  one  of  the  first  labors  of  "The  Friends 
of  the  Insane"  to  establish  fellowships  in  all  accessible 
universities  for  the  study  of  the  physical  basis  of  the 
insanities.  The  millions  now  squandered  on  ostenta- 
tious custody  in  private  madhouses  could  be  well  saved 
by  placing  the  fifty  and  the  hundred  and  fifty  dollar  a 
week  patients  in  the  State  institutions  and  using  this 
money  in  promising  investigations  of  the  origin  if  not 
the  cure  of  the  disease.  The  universities  have  the  men 


DEMENTIA  PRECOX.  31 

in  training,  the  laboratories,  the  libraries  and  the  men- 
tal and  cultural  surroundings  necessary  for  this  long 
hunt  into  the  darkest  and  most  weird  continent  of  hu- 
man ignorance.  Ten  such  fellowships  in  one  of  our 
larger  universities  could  be  maintained  for  twenty 
thousand  dollars  a  year.  This  money  could  be  saved 
by  transferring  twenty  patients  from  the  utterly  use- 
less, if  not  dangerous,  luxuries  of  our  private  sana- 
toriums  to  the  equally  sanitary  wards  of  the  State  asy- 
lums. -It  is  not  beyond  the  hope  of  the  human  heart, 
it  does  not  overreach  our  confidence  in  the  ingenuity 
and  subtlety  of  the  human  mind,  it  does  not  certainly 
surpass  the  precedents  of  the  past,  that  by  such  a 
united  attack  on  ignorance  a  way  could  be  found  for 
cure  and  prevention  of  the  insanities  of  the  young. 

\\hile  most  of  the  psychiatrists  are  following  Freud 
and  Jung  in  their  mental  unravelings,  a  few  keep  in 
the  path  of  true,  sane,  scientific  and  material  investi- 
gation. They  see  in  the  first  prodrome  of  dementia 
precox  the  methyl-like  toxemia  which  at  last  verges 
into  mania,  katatonia  and  dementia.  They  see  the 
poisonous  hydrocarbon  in  the  acetone  breath  of  each 
exacerbation.  They  mark  the  antitoxic  action  of  an 
accidental  erysipelas  or  typhoid  when  a  dementia  pre- 
cox case  shows  a  comet-like  sanity  during  the  disease 
and  often  for  weeks  afterward.  The  osteomalacia 
which  many  of  these  patients  show  seems  only  to  con- 
firm the  toxic  etiology  of  the  disease  of  which  insanity 
is  the  overshadowing  symptom. 

When  the  toxins  which  produce  the  many  diseases 
of  which  dementia  precox  is  a  symptom  are  chemically 


32  ESSAYS. 


recognizable,  then  it  will  be  time  to  find  a  means  of 
their  elimination,  destruction  or  prevention.  Until 
that  time,  let  us  be  overactive  and  oversanguine  rather 
than  coldly  agnostic. 


ARE  ANY  INSANITIES  CURABLE  OR  PRE- 
VENTABLE? 


THE  insanities  of  the  aged  are  a  part  of  senility.  The 
insanities  of  the  syphilitic  are  a  part  of  the  destructive 
processes  incident  to  the  infection.  These  two  ter- 
minal symptoms,  the  one  of  old  age,  the  other  of 
spirocheta  pallida  infection,  are  alike  in  their  generic 
etiology.  The  insanities  of  the  young  are  placed  in  a 
separate  category.  There  is  every  reason  to  believe 
that  dementia  precox  is  a  toxic  process.  It  is  initiated 
by  symptoms  quite  various  in  different  individuals, 
all,  however,  plainly  of  toxemia.  It  is  characterized 
by  exacerbations  and  remissions,  seasonable  or  cycli- 
cal. The  conditions  of  the  excretions,  of  the  kidneys, 
of  the  skin  and  of  the  lungs,  are  positively  indicative 
of  erroneous  metabolism.  There  is  usually  a  long  pro- 
drome of  intestinal,  or,  better,  of  digestive  disorders. 
During  the  acute  stages  acetone  appears  in  the  breath 
and  urine,  and  marked  changes  go  on  in  the  blood. 

Every  physical  sign  of  disease  is  overshadowed  in 
the  minds  of  the  alienists  by  the  psychical  manifesta- 
tions. The  medieval  assumption  is  accepted  as  a  sci- 
entific fact — that  the  person  is  possessed  of  a  devil  or 
obsessed  of  an  illusion.  All  the  changes  which  disease 
has  wrought,  or  may  in  the  future  produce,  in  the  pa- 
tient's body,  are  simply  the  workings-out  of  a  deluded 
mind  upon  a  body  hereditarily  defective.  The  possi- 
bility of  the  reverse  never  occurs  to  the  true  and  loyal 
psychiatrist  more  than  it  does  to  the  faithful  Christian 

33 


34  ESSAYS. 

Scientist.  The  remarkable  cures  which  they  are  each 
of  them  able  to  produce  upon  the  hysterical,  confirm 
them  in  their  faith  and  preclude  any  chemical  or  nutri- 
tional study. 

There  are  more  than  150,000  insane  in  the  asylums 
of  the  United  States.  Of  these,  half  belong  to  the 
senile  and  syphilitic,  whose  stay  in  the  custody  of  the 
State,  from  the  very  nature  of  the  conditions,  must  be 
rather  short.  At  least  30  per  cent,  are  of  the  adoles- 
cent group.  They  remain  in  custody,  in  spite  of  tuber- 
culosis, typhoid,  pellagra  and  erysipelas,  a  very  long 
time. 

The  expense  of  custody  of  an  insane  person  varies 
between  $150  and  $200  a  year.  In  the  public  institu- 
tions a  small  proportion  of  patients  have  estates  from 
which  the  State  is  reimbursed.  In  the  private  institu- 
tions $25  to  $250  per  week  is  charged  for  more  ostenta- 
tiously luxurious  but  not  more  curative  custody.  The 
private  corporations  that  care  for  the  insane  are  not 
subject  to  any  effective  official  supervision,  and  they 
support  no  research  or  educational  work.  A  few 
States  have  so-called  psychopathic  hospitals.  So  far 
as  published  work  indicates,  they  have  no  adequate 
clinical  laboratories  and  laboratory  kitchens.  The  only 
two  of  which  the  writer  has  an  intimate  knowledge 
have  no  adequate  bathing  facilities.  These  institutions 
are  not  making  any  vigorous  onslaught  upon  our  ig- 
norance of  any  of  the  insanities. 

The  grand  total  of  State  expense  for  the  care  and 
custody  of  the  insane  cannot  be  far  short  of  $50,- 
000,000  a  year.  The  expense  to  the  country  as  a 


CURABLE  OR  PREVENTABLE.  35 

nation,  through  loss  of  at  least  25,000  citizens  a  year, 
is  equal  to  a  state  of  constant  war.  If  every  State 
expended  in  research  10  per  cent,  of  the  perpetual 
dump  into  custody,  a  small  squad  of  scientists  would 
be  at  work  on  measures  designed  to  end  this  inglorious 
largess. 

It  appears  to  us  that  through  the  researches  in 
physiological  chemistry,  the  first  surveys  of  this  dark 
continent  of  pathology  is  being  staked  off.  The  long- 
known  toxicity  of  the  alcohol  radicals,  of  which  methyl 
alcohol  -is  the  most  alarming  example,  has  been  given 
new  significance  in  relation  to  sleep  and  fatigue.  The 
action  of  mineral  poisons  and  physiologic  processes 
sets  free  the  carbohydrate  radicals,  which  are  the  real 
toxic  and  narcotic  elements,  as  well  as  the  long-known 
signs  of  various  constitutional  diseases.  In  pure 
science  aid  must  come. 

The  exclusion  of  all  the  insane  from  the  regular 
profession  and  from  their  hospitals,  puts  all  the  re- 
sponsibility as  well  as  it  gives  all  the  opportunity  to 
the  officers  of  the  State.  If  they  expect  to  hold  the 
positions  they  occupy,  they  must  clean  house  and  make 
their  asylums  into  hospitals.  They  must  stop  the 
building  of  castellated  fortresses  and  construct  tem- 
porary workshops,  laboratories  and  bath-houses  on  the 
ground.  Instead  of  sitting  with  a  fateful  complacency 
in  their  own  luxurious  quarters,  they  must  organize  a 
squad  of  scientific  sappers  and  miners  and  fearlessly 
and  hopefully  assault  our  ignorance. 


THE  CONDITION  OF  THE  BLOOD  IN  THE 
INSANE. 


THE  insane  suffer  from  all  the  diseases  which  afflict 
the  rational,  among  them  the  so-called  diseases  of  the 
blood.  The  diseases  of  the  blood  are  for  the  most  part 
symptomatic,  and  it  would  be  unreasonable  to  con- 
sider them,  apart  from  other  symptoms,  as  indicative 
of  a  more  general  and  primary  disease.  In  any  case 
the  study  of  the  conditions  of  the  blood  in  the  insane 
is  admitted  as  desirable,  though  it  is  conceded  that  it  is 
much  neglected. 

As  early  as  1854  W.  L.  Lindsay  published  a  mono- 
graph, "The  Histology  of  the  Blood  Changes  in  the  In- 
sane," and  since  that  time  many  articles  have  been 
published  on  special  aspects  of  the  subject,  each  au- 
thor led  by  his  own  prejudices  or  those  of  his  time. 
Notice  especially  (not  for  their  value,  but  to  show  the 
bias  and  superficiality  of  these  studies)  articles  by  the 
following  authors:  Seppelli,  1886;  Smyth,  1890;  We- 
ber, Agostini,  d'Abunclo,  and  also  Krypiakiewicz, 
1892;  Roncoroni  and  also  Verster,  1894;  Burton,  1895  ; 
Summers  and  also  Harrison,  1896;  Ceni,  1897;  Hev- 
erech-Kobliha.  1898;  Lambranzi,  1899;  Mackie  and 
also  Wherry,  1901. 

Any  real  knowledge  of  the  histology,  physiology  and 
pathology  of  the  blood  cannot  be  said  to  have  existed 
previous  to  1890,  and  the  most  important  reactions 
of  the  blood  have  been  perfected  since  1900.  Even 
now  there  are  many  conditions  which  are  clinically 

37 


38  AYS. 

recognized  that  have  not  been  followed  up  chemically 
and  morphologically.  Of  this  general  fact  every 
reader  will  recognize  that  puerperal  toxemia  is  a  la- 
mentable example.  Osteomalacia,  fragilis  ostium,  my- 
ositis  ossificans,  arthritis  deformans,  pernicious  anemia 
and  melena  neonatorum  are  equally  striking  but  less 
familiar  instances  of  the  same  state  of  affairs. 

The  disease  in  each  case  is  named  for  the  overshad- 
owing symptom,  but  in  every  instance  the  foundation 
is  a  toxemia.  The  toxemia  in  eclampsia  is  apparent 
to  every  physician  and  obstetrician,  and  practically  the 
same  toxin  is  found  in  the  visual  disturbances,  in  the 
uncontrollable  vomiting,  if  not  in  the  so-called  physio- 
logical nausea  of  pregnant  women.  No  one  believes 
that  the  blood  is  primarily  at  fault.  Clinically,  most 
patients  recover  after  an  artificial  delivery,  and  symp- 
tomatically  the  gravest  symptoms  are  relieved  by  bleed- 
ing and  replacing  the  lost  blood  with  a  normal  salt  so- 
lution. In  spite  of  the  frequency  of  this  disease,  the 
labors  of  the  obstetrician  have  been  fruitless  in  finding 
an  adequate  and  demonstrable  source  of  the  toxin  (v. 
Culbertson,  Surgery,  Obstetrics  and  Gynccology,  April, 
1910).  It  is  not  to  be  wondered  at,  then,  that  the 
rarer  toxemias  of  the  conditions  mentioned  above 
should  still  remain  utterly  unknown. 

There  are  two  distinct  reasons  for  studying  the  blood 
of  the  insane  as  soon  as  the  patient  comes  under  ob- 
servation ;  the  first  is  to  discover  the  presence  of  a 
well-known  underlying  disease,  such  as  septic  endo- 
carditis, of  which  the  acute  mania  is  an  overshadowing 
symptom,  and  thus  put  the  patient  in  the  best  possible 


CONDITION   OF   THE  BLOOD.  39 

condition  to  be  treated ;  the  second  is  to  make  such  re- 
searches as  will  elucidate  the  problems  of  insanity. 

Every  institution  for  the  insane  receives  maniacal 
patients  that  are  suffering  from  all  sorts  of  physical 
ills,  from  fractured  skulls  and  perineal  lithotomies  to 
gonorrheal  pyonephroses  and  streptococcus  septice- 
mias.  The  examination  of  the  blood  in  some  of  these 
patients  would  result  in  their  immediate  recognition 
as  acute  hospital  cases,  and  a  part  of  them  at  least 
would  be  diagnosed  before  they  came  to  autopsy,  and 
possibly  before  it  was  too  late  for  medical  or  surgical 
therapeutics.  This  contention  I  am  sure  is  denied  by 
no  one. 

There  are,  nevertheless,  many  who  would  think  a  re- 
peated, complete,  careful,  purposeful  study  of  the  blood 
of  the  insane  in  our  public  institutions  unnecessary  and 
time-consuming  routine.  It  would  perhaps  at  once  sep- 
arate the  blood  findings  due  to  institutional  life  from 
those  due  to  the  primary  diseases.  It  would  perhaps 
give  a  hint  of  epidemics,  such  as  the  epidemic  of  pel- 
lagra at  Peoria,  before  it  had  involved  so  large  a  num- 
ber. But  it  is  in  order  to  explain  and  possibly  utilize 
some  of  the  incomprehensible  reactions  of  the  insane 
to  the  infectious  diseases  that  this  study  should  be  car- 
ried out.  More  than  thirty  years  ago  Savage  noticed 
that  a  considerable  number  of  patients  recovered  from 
their  insanity  during  typhoid,  erysipelas  and  extensive 
suppurative  disease,  and  since  that  time  a  great  many 
observations  of  the  same  sort  have  been  made.  Prob- 
ably the  most  uniform  and  general  improvement  has 
occurred  in  typhoid,  but  the  most  permanent  and  com- 


40  ESS  A  VS. 

plete,  in  both  acute  and  chronic  cases,  in  maniacal  and 
demented  cases,  has  followed  streptococcus  or  ery- 
sipelatous  disease.  In  two  epidemics  at  Independence, 
la.,  Boody  noticed  that  25  per  cent,  of  those  attacked 
by  typhoid  made  great  physical  improvement  on  recov- 
ery, and  16  per  cent,  of  the  dements  improved  men- 
tally in  a  remarkable  manner,  but  relapsed ;  one  case  of 
catatonia  and  one  case  of  acute  mania  recovered  com- 
pletely and  permanently.  Even  patients  that  have  been 
insane  for  many  years  have  recovered  and  been  dis- 
charged from  the  asylum  after  recovering  from  the 
typhoid.  Twenty-one  cases  that  were  observed  by 
Campbell  made  great  improvement  during  and  after 
the  typhoid,  and  six  left  the  asylum  clear-minded. 

Bullin  and  Goodall  suggested  the  production  of  an 
artificial  streptococcus  infection,  but  I  find  no  reports 
of  their  experiments.  Some  work  in  the  same  direction 
has  been  done  by  the  Italians.  Coley's  toxin,  which  has 
been  so  successful  in  the  treatment  of  sarcoma,  has 
also  been  empirically  used  in  a  few  cases  of  insanity. 
1  The  Scotch  alienists  are  making  very  extensive  study 
of  the  blood  of  the  insane,  and  have  tried  to  secure 
effective  hemolytic  reactions,  but  so  far  their  work  is 
valuable  only  in  fixing  the  toxic  origin  of  insanity  on  a 
firmer  basis.  Much  and  Holzman,  of  the  Eppendorf 
Hospital  (1909),  have  raised  a  tempest  in  a  teapot  by 
publishing  the  results  of  their  cobra-poison  reaction. 
They  found  that  all  cases  of  dementia  precox,  and  a 
part  of  the  manic-depressive  group,  invariably  reacted 
to  this  poison,  while  other  insane  patients  and  most 
rational  people  did  not.  A  great  number  of  other 


CONDITION  OF   THE  BLOOD.  41 

German  hematologists  repeated  these  experiments,  but 
so  far  they  do  not  agree  in  their  criticisms. 

It  is  sometimes  assumed  that  the  improvement  that 
comes  to  the  insane  during  typhoid,  erysipelas,  scarlet 
fever,  smallpox  or  other  disease,  is  due  to  the  high 
temperature.  Therefore,  artificial  hyperpyrexia  has 
been  tried,  but  without  result. 

The  appearance  of  polycythemia  and  methemoglo- 
binemia  in  cases  of  dementia  precox,  and  the  demon- 
stration by  Gibson  (Quarterly  Journal  of  Medicine, 
1909)  of  the  intestinal  origin  of  the  toxemia  of  which 
these  conditions  of  the  blood  are  symptomatic,  and 
also  the  well-known  frequency  of  osteomalacia  in  de- 
mentia precox,  excites  our  curiosity  as  to  the  possible 
discoveries  to  be  made  in  this  quarter.  The  coagula- 
bility of  the  blood  in  polycythemia  of  the  insane  has 
been  found  very  high.  As  the  blood  has  flowed  from 
the  median  vein  it  has  piled  up  in  the  bowl  and  fre- 
quently stopped  flowing  by  the  formation  of  a  clot  at 
the  opening.  The  quantity  of  blood  in  proportion  to 
the  weight  of  the  body  has  also  been  found  very  great. 
All  these  facts  show  the  need  of  constant,  frequent 
and  regular  blood  examinations  of  the  most  extensive 
and  exacting  kind. 

Such  examinations,  taken  together  with  other  well- 
indicated  physical  examinations  in  the  institutions 
which  now  segregate  from  the  medical  profession  the 
quarter  of  a  million  of  the  insane  and  monopolize  this 
perfectly  controllable  clinical  material,  would  be  very 
inspiring  to  the  small  corps  of  well-equipped  hema- 
tologists that  our  better  institutions  are  sending  out 


42  ESSAYS. 

each  year.  The  darkest  continent  of  clinical  pathology 
promises  adventures  and  discoveries  which  would  sat- 
isfy the  ambition  of  the  most  strenuous  and  indefatig- 
able. 

But  how  can  such  an  active  campaign  of  research  be 
set  in  motion?  The  pressure  for  this  study  cannot 
come  from  the  insane  themselves.  There  is  no  compe- 
tition among  State  institutions.  The  superintendents 
have  a  hard  time  now  to  keep  things  running  smoothly. 
The  patients'  needs  and  the  scientific  opportunities  are 
not  pressing  so  hard  as  the  discipline,  the  patronage 
and  the  appropriations.  It  is  left  to  the  friends  of  the 
imane  and  the  medical  profession,  from  whose  obser- 
vation and  care  they  have  been  removed,  to  insist  on 
the  regular,  frequent,  complete  and  purposeful  study 
of  the  blood  of  the  wards  of  the  State,  to  the  end  that 
some  inroads  be  made  on  our  ignorance  of  the  condi- 
tions of  which  the  insanities  are  the  compelling  symp- 
toms. 


SEROLOGY  AND  PSYCHIATRY. 


THE  defenceless  find  a  defender  in  the  brave,  the  help- 
less a  helper  in  the  strong.  Who  is  strong  enough  to 
help  the  lost  mind  to  find  itself? 

We  are  so  rich  that  we  spend  millions  every  year  to 
keep  the  insane  out  of  our  way.  We  have  built  anti- 
quated lunatic  asylums  which  we  now  call  hospitals, 
but  are  they  in  fact  hospitals  or  are  they  hospices  ?  It 
is  the  duty  of  the  hospital  as  it  is  the  duty  of  the  doctor 
to  cure  the  sick.  The  European  hospital  of  1820  was 
a  dreadful  place.  Von  Langenbeck  came  home  from 
England  and  introduced  relative  cleanliness  into  hos- 
pital practice.  Lister  learned  the  lesson  of  antisepsis 
from  Pasteur's  study  of  the  silkworm.  When  the 
routine  and  conservatism  of  the  hospitals  of  the  world 
had  been  thoroughly  conquered  by  the  antiseptic  meth- 
ods and  by  the  ceremonials  of  cleanliness,  gangrene — 
the  now  forgotten  hospital  gangrene — erysipelas  and 
pus  disappeared,  and  the  injured  patients  were  quickly 
cured,  sent  home  and  their  beds  given  to  the  needy. 
The  average  stay  of  each  patient  in  the  hospital  was 
reduced  from  weeks  and  months  to  days,  and  the 
utility  of  the  hospital  multiplied  without  increasing  its 
capacity  or  expense. 

As  it  is,  our  madhouses  contain  200,000  citizens  out 
of  80,000,000,  and  the  proportion  is  growing.  In 
Washington  State  one  out  of  every  238  citizens  is  a 
ward  of  the  State — insane,  criminal  or  defective.  Of 
all  the  millions  spent  in  custody,  not  one  dollar  is  spent 

43 


44  ESSAYS. 

in  the  only  rational  and  legitimate  functions  of  a 
hospital — in  cure. 

Of  course,  we  do  not  know  the  cause  of  the  insani- 
ties. Sometimes  we  can  say  when  we  see  a  per.-on  that 
he  is  crazy.  Likely  'enough  he  is,  but  when  we  get 
down  to  bottom  rock  and  tell  why  we  say  so.  there  is 
nothing  left  for  us  to  say  but  "  'cause  he  is." 

In  our  lunatic  asylums  no  systematic,  adenuate;  per- 
sistent or  creditable  effort  is  made  to  search  out  the 
causes  of  the  insanities,  nor  to  vigorously  prosecute 
rational  methods  of  cure.  Our  madhouses  ate  with- 
out laboratories,  clinical  or  research;  they  have  no 
therapeutic  gymnastic  apparatus  in  use ;  no  occupa- 
tional or  re-educational  training  schools  for  the  con- 
valescent, and  no  baths  commensurate  with  the  needs 
even  of  present-day  ideals. 

Worse  than  all  this  there  has  come  over  a  great  class 
of  alienists  a  withering  mould  of  mysticism  from  the 
East.  The  head  of  the  whole  faculty  of  a  sovereign 
State,  a  man  on  whom  the  education,  culture  and  ex- 
perience of  the  world  has  expended  itself,  has  come 
forth  to  say  "mental  diseases  are  the  results  .of  mental 
tangles,"  and  that  "mere  disposition  is  not  disease." 
When  the  head  of  a  system  puts  forth  sentiments 
worthy  of  a  Christian  scientist  or  an  emasculated 
monk,  what  may  the  psychologic  prestidigitations  of 
the  State  laboratory  bring  forth  ? 

In  another  locality  the  scion  of  a  most  distinguished 
medical  ancestry  who  adds  social  prestige  to  verr.tiit1 
accomplishments,  has  given  his  professional  vise  to  the 
religio-medical  laying-on-of-hands,  known  as  the 
Emmanuel  movement. 


SEROLOG*'  AXD  PSYCHIATRY.  45 

From  these  great  lights  it  is  only  step  by  step  oown 
to  the  throng  of  physicians,  psychiatrists,  healers  and 
grafters  of  one  sort  and  another;  here  using  psycho- 
analytic methods  and  there  hypnotism  or  hypnoidism, 
here  a  tangle  of  electrical,  optical,  acoustic,  gustatory 
and  olfactory  paraphernalia  of  delusional  complexity, 
and  there  reading  the  •etiology,  pathology  and  indica- 
tions for  treatment  in  the  pupil  of  the  eye,  studici  in 
a  dark  room  with  a  tallow  dip  and  a  thirty-cent  magni- 
fying glass.  ., 

Their  publications  are  multiple  and  some  of  them 
magnificent  and  adorned  with  names  seen  in  better 
company  (e.g.,  "Psychotherapy,  a  Course  of  Read- 

ing")-   ' 

In  spite  of  this,  the  compact  and  invincible  army  of 
scientific  investigators  goes  on  sapping  and  mining  the 
entrenchments  of  ignorance  and  mystery.  There  are 
long  periods  of  apparent  inactivity  and  barren  en- 
deavor, but  these  heart-sickening  preparations  are  nec- 
essary to  a  victorious  assault. 

At  the  present  time  the  chemico-physiologic  study 
of  the  blood  is  bringing  forth  its  first-fruits.  It  is  not 
enough  that  a  reliable  test  for  typhoid  is  in  the  hands 
of  every  doctor,  and  that  an  equally  serviceable  test 
of  syphilis  is  at  his  disposal  in  the  hands  of  the-hema- 
tologist  or  professional  pathologist.  It  is  not  enough 
that  a  method  of  artificial  immunity  is  in  his  arma- 
mentarium against  diphtheria,  rabies  and  tetanus.  The 
methods  which  attend  the  study  of  these  phenomena 
place  the  inateria  morbi  in  new  exposure  and  subject 
it  to  a  new  method  of  observation  and  attack. 


46  ESSAYS. 

The  real  scientist  and  student-physician  is  not  slow 
to  take  up  these  weapons  of  cure.  Against  the  mental 
diseases,  however,  not  much  progress  has  been  made, 
either  in  discovering  their  etiology,  solving  their  path- 
ology or  securing  a  cure. 

There  is  a  deadly  parallel  between  eclampsia,  ma- 
lignant jaundice,  acute  yellow  atrophy  of  the  liver, 
phosphorus  poisoning,  delayed  chloroform  poisoning 
and  dementia  precox.  In  all  these  conditions  there  are 
physical  findings  of  intoxication  and  starvation.  In 
all  these  are  pronounced  nervous  phenomena.  In  all 
these  the  loss  of  weight,  the  acetone  breath,  the  dilated 
pupil  and  urinary  findings  indicate  grave  errors  of 
metabolism. 

There  remains  little  doubt  in  the  mind  of  the  path- 
ologist that  eclampsia  is  due  to  an  intoxication  from 
substances  produced  in  the  fetal  membranes.  Ec- 
lampsia is  a  manifestation  of  this  intoxication,  due 
apparently  to  an  increased  susceptibility  of  the  patient 
toward  the  end  of  gestation  to  the  toxin  which  is 
present  from  the  beginning  of  pregnancy. 

The  evidence  is  increasing  that  the  morning  sick- 
ness, looked  upon  as  physiologic  by  our  ancestors,  the 
uncontrollable  vomiting  of  pregnancy,  and  many  other 
complications  of  childbearing,  are  due  to  the  same  tox- 
ins developed  in  the  surroundings  of  the  fetus.  This 
toxin  is  so  uniformly  present  in  early  pregnancy  that 
it  has  been  used  by  Fieux  and  Mauriac  as  diagnostic 
of  that  condition.1  The  appearance  of  eclampsia  seems 

1  Annales  de  Gynecologic  et  Obstetrique,  vol.  7,  p.  65,  Feb- 
ruary, 1910. 


SEROLOGY  AXD  PSYCHIATRY.  47 

to  be  due  to  a  sort  of  anaphylaxis  which  the  patient 
attains  from  a  variety  of  accidents  or  causes. 

That  etiologically  unsolved  problem,  acute  yellow 
atrophy  of  the  liver,  is  indisputably  toxic.  V.'hat  is  the 
source  of  the  toxin  we  may  only  guess.  Why  it  acts 
in  such  a  fulminating  manner  is  another  mystery. 

Of  all  the  parallels,  that  by  phosphorus  poisoning 
and  acute  yellow  atrophy  are  most  intricate.  They 
verge,  however,  into  those  of  eclampsia,  and  eclampsia 
is  related  by  many  common  factors  to  puerperal  in- 
sanity. In  the  earliest  reported  cases  of  acute  yellow 
atrophy  the  mental  symptoms  are  given  great  prom- 
inence (Frerichs,  Clinical  Treatise  on  Diseases  of  the 
Liver,  New  Sydenham  Society,  London,  1860,  pp. 
194-196),  and  the  pathologic  findings  in  all  these  con- 
ditions have  a  remarkable  analogy. 

The  early  toxemia  of  pregnancy,  on  which  Fieux 
and  Mauriac  make  their  hemolytic  diagnosis,  is  due  to 
a  period  of  maximal  chorionic  activity,  and  is  based 
upon  a  vello-toxemia.  It  was  Veit  (1901)  who  sug- 
gested that  the  toxemia  of  pregnancy  was  a  syncytial 
toxemia,  and  occurred  from  a  lack  of  syncytolysin  on 
the  part  of  the  mother.  The  French  have  long  held  to 
the  autotoxic  nature  of  all  the  toxemias  of  pregnancy, 
from  acute  yellow  atrophy  to  puerperal  mania.  There 
are  great  changes  in  metabolism  during  pregnancy, 
which  resemble  similar  changes  during  menstruation 
as  a  storm  resembles  a  shower. 

Adolescence,  like  gestation,  is  attended  by  a  revo- 
lution in  metabolism,  not  always  happy  in  its  termi- 
nation. It  is  the  most  critical  period  of  life,  and  is 


48  ESSAYS. 

attended  by  dangers  and  catastrophes,  of  which  de- 
mentia precox  is  the  most  terrible.  This  condition  is 
by  all  odds  the  most  mysteriously  melancholy  and  the 
most  pitiably  hopeless  of  medical  aid  that  can  befall 
the  human  soul.  The  body  is  overcome  by  vague 
distress,  the  mind  by  static  indecision ;  nutrition  fails, 
excretions  are  perverted,  the  muscular  system  is  com- 
pletely overcome  by  the  toxemia,  and  the  hematopoetic 
apparatus  is  thrown  out  of  time.  It  is  not  a  sudden 
and  surging  wave  of  intoxication,  but  an  inexorable 
rising  tide  of  toxemia,  the  source  of  which  is  unknown 
and  practically  unsought. 

It  is  difficult  in  speaking  of  adolescent  insanity  to 
be  at  once  definite  and  unmistakeable,  and  yet  use  the 
clinical  terms  of  the  alienists.  There  are  no  patho- 
logic terms  applying  to  the  insanities  of  the  young. 
General  paresis  and  senile  dementia  have  some  patho- 
logic foundation.  The  search  for  some  toxic  founda- 
tion of  manic-depressive  insanity  has  already  been 
undertaken.  Bruce  (Journal  of  Mental  Science,  Oc- 
tober, 1910,  vol.  Ivi,  p.  630)  has  made  a  promising 
beginning.  Much  and  Holzman  (Munch.  Med.  Woch., 
May  18,  1901,  p.  1001)  have  applied  the  cobra  venom 
hemolytic  test  to  the  insane  with  results  which  have 
been  confirmed  by  many  in  every  essential  degree. 
Much  (Berliner  klin.  Woch.,  vol.  Ixvii,  p.  1492,  August, 
1910)  has  further  extended  the  practice  of  serology 
to  psychiatry  and  given  three  distinct  serologic  tests, 
which  should  become  a  routine  in  every  madhouse  that 
claims  to  be  a  hospital,  and  be  continued  and  extended 
as  science  furnishes  new  methods.  One  is  the  Wasser- 


SEROLOGY  AND  PSYCHIATRY.  49 

mann  test,  which  should  not  be  neglected  by  any 
clinician;  the  second  is  the  cobra  vemon  reaction  of 
Much  and  Holzman,  and  the  third  is  Geissler's  pre- 
cipitin  test.  None  of  these  tests  are  of  ultimate  or 
positive  diagnostic  significance,  but  they  penetrate  a 
little  way  into  the  unknown.  If  there  is  any  mad- 
house that  would  become  in  fact,  as  well  as  in  name,  a 
hospital  for  the  insane,  no  cytolitic  or  other  chemical, 
physical  and  rational  investigation  can  be  neglected 
until  our  ignorance  of  the  condition  has  been  cleared 
away.  Such  trifling  numbers  as  Bruce  reports  (fif- 
teen), or  the  arms-length  examinations  made  in  New 
York  of  patients  in  Connecticut,  cannot  possibly  meet 
the  requirements  of  this  pioneer  study. 

In  less  than  ten  years  the  contagium  vivum  of  syph- 
ilis has  been  discovered,  and  an  absolutely  new  remedy 
has  been  put  forth.  More  important,  if  possible,  than 
this  discovery,  has  been  the  extension  of  the  reaction 
of  Wassermann  to  the  almost  infallible  diagnosis  of 
syphilis.  By  this  new  hemolytic  method  the  presence 
of  the  disease  can  be  established  with  certainty  and 
celerity,  and  the  effect  of  treatment  can  be  guided  and 
checked. 

Out  of  the  millions  now  spent  in  custody  of  the  in- 
sane, by  a  method  that  insures  the  most  perfectly 
unhindered  destructive  action  of  the  disease  upon  the 
patient,  and  imprints  deeper  the  inevitable  injury  of 
the  intoxication  of  the  venom  of  the  insanities,  not  a 
mite  is  devoted  to  research.  The  segregation  of  the 
insane  precludes  any  meddling  by  the  methods  of  the 
ordinary  hospital,  and  outside  of  isolated,  fickle  and 


50  ESSAYS. 

trifling  attempts,  no  serious  study  of  what  the  alienists 
call  somatic  conditions  exist.  The  psychopathic  wards, 
institutes  and  hospitals  are  devoted  to  playing  horse 
with  hysterics,  and  are  equipped  almost  as  well  as  the 
institutites  and  sanitaria  of  some  pupil-gazing  quacks. 

When  we  consider  the  almost  uniformly  positive 
Much-Holzmann  reaction  in  dementia  precox  (a  uni- 
formity almost  equal  to  that  of  syphilis  to  the  Was- 
sermann),  we  cannot  longer  fail  to  use  and  require  its 
use  for  diagnosis,  and  continue  our  observations  until 
more  light  has  been  thrown  upon  the  subject  o  r  better 
methods  proposed. 

It  may  seem  that  these  examinations  are  fruitless, 
and  that  remedies  are  what  we  want.  Perhaps  they 
are ;  but  we  want  more  than  all  to  dispel  mystery  and 
ignorance.  Each  newly  discovered  fact  opens  up  new 
vistas  of  ignorance  and  new  possibilities  of  conquest. 
Let  us  see  to  it  that  \ve  take  the  next  step  at  once. 


MYOSITIS    OSSIFICANS— A    LESSON. 


MEDICAL  literature  is  strewn  with  the  records  of 
unassimilated  observations.  Each  advance  guard  of 
science  goes  through  this  rubbish-heap  of  literature 
and  picks  out  such  specimens  as  their  new  conceptions 
of  science  can  explain.  The  mass  of  clinical  observa- 
tions gradually  centers  about  certain  peaks  of  fre- 
quency or  certain  congresses  of  association,  and  out  of 
these  groupings  of  nebulous  uncertainties  real  scientific 
deductions  at  last  appear. 

The  ossified  man  of  the  dime  museum  held  a  tragic 
place  in  the  nightmares  of  our  youth  and  later  in  our 
scientific  fancies. 

Myositis  ossificans  is  looked  upon  as  a  condition 
common  enough  to  receive  a  section  in  our  nosology. 
It  is  usually  given  as  (1)  a  myositis  ossificans  pro- 
gressiva,  which  begins  in  infancy  or  adolescence,  with- 
out known  adequate  cause,  and  continues  to  the  end  of 
life,  and  as  (2)  traumatic  myositis  ossificans,  which 
results  from  local  irritation,  and  may  terminate  shortly 
in  local  arrested  ossification  of  adjoining  muscles.  The 
former  are  the  rarer  in  point  of  numbers,  and  more 
compact  in  point  of  consistent  uniformity  of  symp- 
toms, course  and  termination ;  the  latter  are  more  nu- 
merous and  more  variable.  This  group  probably  is 
composed  of  several  distinct  pathologic  groups,  which 
accidentally  manifest  the  grotesque  symptom  of  ossi- 
fying myositis,  and  are  therefore  ignorantly  huddled 

51 


52  ESSAYS. 

together  in  this  artificial  category.  We  find  here  cases 
of  syphilitic  ossifying  periarthritis  and  myositis,  sar- 
comatosa  fibrosa  and  ossifying  periostitis,  besides  the 
true  ossifying  myositis  aroused  locally  by  injury  or 
infection. 

The  clinical  entity  now  known  as  ossifying  myositis 
is  looked  upon  as  a  general,  diffuse,  chronic  or  sub- 
acute  inflammation  of  muscles,  followed  by  a  more  or 
less  complete  ossifying  process,  and  due  to  a  congeni- 
tal (  ?)  fault  of  a  mesoblastic,  mystical,  intangible  and 
irremediable  if  not  inscrutable  nature.  It  is  never 
hereditary,  and,  although  its  appearance  does  not  in- 
terfere with  procreation  no  offspring  have  ever  been 
afflicted  with  the  same  condition. 

Rolleston  (Clinical  Journal,  1901,  v.  17,  p.  209)  is 
wholly  given  up  to  the  idea  or  theory  of  an  essential 
error  in  mesoblastic  development  as  the  fundamental 
cause  of  osteofying  process.  He  holds  that  the  same 
cause  exists  in  the  traumatic  group,  and  that  it  is  not 
sufficiently  vick  us  a  fault  in  such  cases  to  produce 
the  bony  tumors  without  a  traumatism,  while  in  the 
progressive  type  it  is  a  more  serious  error,  and  the  os- 
sification of  muscles  appears  spontaneously  and  inev- 
itably. 

The  fact  that  certain  unrelated  diseases,  such  as  the 
acute  infectious  diseases,  tuberculosis,  and  even  ac- 
quired syphilis,  often  antedate  the  onset  of  progressive 
ossifying  myositis,1  seems  to  support  such  a  thesis. 
There  are  many  other  cases  reported  of  a  similar  kind. 

1  De  Witt:  Myositis  Ossificans,  Am.  Jour.  Med.  Sci.,  1900, 
vol.  120,  p.  295. 


MY  OS  IT  IS   OSSIFICANS.  S3 

A  patient  that  had  never  shown  any  tendency,  even  to 
osteophytes,  suffers  injury  resulting  in  local  ossifying 
myositis,  and  immediately  there  follows  a  progressive 
general  myositis  (Pincus,  1896).  These  peculiar  clin- 
ical histories  are  complicated  by  equally  inexplicable 
microscopic  findings.  The  degree  of  ossification  dif- 
fers with  the  patient,  and  even  in  different  patients. 
In  one  the  osteophytes  are  largely  displacements  of 
true  muscular  elements,  and  are  surrounded  by  fascia- 
like  capsules  ;  in  others  the  bony  masses  include  micro- 
scopic muscle  elements  not  yet  destroyed.  Here  there 
is  a  myxomatous  tumor  surrounded  by  spicules  or  cap- 
sules of  bone,  while  near  by  there  is  a  thoroughly  ebur- 
nated  osteophyte.  The  tumor  which  has  displaced 
these  muscular  elements  does  not  always  remain  de- 
tached from  the  bone  to  which  the  muscle  is  inserted 
or  from  which  it  arises.  It  then  resembles  the  splint 
bones  of  the  horse  and  other  animals.  However,  the 
muscles  of  the  legs  are  exceptionally  involved,  and 
suggest  a  wholly  different  etiology.  When  both  ex- 
tremities of  the  muscles  are  thus  ossified  the  surround- 
ing joint  is  rendered  immobile. 

The  similarity  to  embryonal  development  found  in 
some  of  these  osteophytes  led  Virchow  to  assign  these 
tumors  to  a  category  between  inflammatory  new 
growths  and  malignant  degenerations. 

Clinically,  every  point  of  attack  is  preceded  by  a  dis- 
tinct myositis,  with  local  and  constitutional  symptoms. 
In  the  former  even  the  skin  over  the  muscle  takes  part. 

The  reader  would  naturally  think  of  rhizomelic 
spondylosis  and  of  osteitis  deformans  in  this  connec- 


54  ESSAYS. 

tion.  In  the  former  condition  the  intervertebral  carti- 
lages are  removed,  and  eventually  bony  ankylosis  ob- 
literates all  joints.  In  the  latter,  deformities  are  great, 
but  the  articular  cartilages  remain.  In  this  connec- 
tion also,  leontiasis  ossium  would  be  bound  to  present 
itself,  and  that  very  mixed  example  of  bony  over- 
growth found  in  osteoarthropotha  hypertrophica  pul- 
montim  (Bamberger,  1890;  Marie,  1891  ;  Thayer, 
1896).  Here  there  is  adequate  pathology,  but  its 
relations  to  osteoid  hypertrophy  and  calcification  are 
not  clear. 

There  are  certain  conditions  in  which  overgrowth  of 
bone,  somewhat  similar  to  the  osteoarthropathy  of 
Marie,  are  accompanied  by  jaundice,  in  which  cases  the 
hypertrophy  is  arrested  by  the  drainage  of  the  gall- 
bladder. Buttenmiller,2  without  chemically  demon- 
strating the  toxines  of  the  cholemia,  which  he  holds 
responsible,  or  even  connecting  such  a  hypothetical  tox- 
ine  with  the  osteophytosis,  does  show  that  cholecystos- 
tomy  actually  arrests  the  disease.  The  bones  become 
normal  and  the  patient  recovers  as  from  the  callus  of  a 
fracture. 

Some  credible  instances  of  resolution  of  the  osteo- 
phytes  have  recently  appeared  in  the  literature.  Gross- 
kurth  (1908)  reports  his  success  with  fibrolysin  in 
treating  osteophytes  appearing  in  the  left  arm  of  a  sol- 
dier after  a  bayonet  wound;  and  Xadler  (Deutsche 
Zeitschrift  f.  Chi-r.,  Bd.  74,  p.  427)  gives  beautiful  X- 
ray  photographs  to  show  the  disappearance  of  extensive 

2  Buttenmiller :  Toxigene  Osteo-Periostitis  Ossiticans  bei 
chronischer  Icterus.  Berl.  k.  Woch.,  1903,  May  25,  p.  1001. 


MYOSITIS  OSSIF1CANS.  55 

bony  masses  of  traumatic  myositis  ossificans,  without 
any  specific  treatment. 

In  the  mind  of  the  contemplative  student  and  clini- 
cian, the  proclivity  toward  osteophytosis  and  other  hy- 
pertrophic  anomalies  of  bones  stands  in  the  category 
of  unexplained  toxemias.  Just  what  the  toxic  element 
is  which  determines  the  onset  of  the  myositis  which  is 
followed  by  ossification,  our  chemists  have  not  deter- 
mined. Not  much  can  be  culled  on  this  subject  from 
the  barren  ^chemical  literature  of  the  past  two  decades 
except  disappointment  (Van  Noorden,  "Metabolism," 
Chicago,  1907,  Vol.  iii,  p.  1275).  The  conspicuous  part 
that  muscles  play  in  metabolism  accounts  for  the  prom- 
inence of  muscular  pathology  and  of  ossifying  pro- 
cesses (i.  e.,  calcifying)  in  particular.  In  chronic  jaun- 
dice in  pulmonary  disease,  in  syphilis  and  in  arthritis 
deformans  there  are  evidences  enough  of  a  toxic  con- 
dition, which  might  with  better  chemistry  be  connected 
with  the  hypertrophic  osteophytosis.  There  are  doubt- 
less often  equally  important  results  of  this  toxemia 
which  we  fail  to  see.  The  bony  hypertrophy  is  too 
bombastic  a  symptom  to  be  overlooked. 

This  so  obvious  and  flamboyant  a  symptom  of  a 
cryptic  intoxication  is  further  associated  in  the  mind  of 
the  contemplative  student  with  other  spectacular  symp- 
toms of  equally  cryptic  conditions. 

Alkaptonuria  is  a  condition  of  abnormal  metabolism 
in  which  one  overmasteringly  conspicuous  symptom, 
an  inky  color,  appears  in  the  urine  without  any  chemi- 
cal reagent  having  been  added  to  it.  The  practitioner 
finds  a  reaction  to  the  acetone  sugar  tests,  but  there  is 


56  ESSAYS. 

no  sugar  present,  and  the  alkaphonttric  is  not  sick.  It 
is  a  life-long  condition,  but  it  is  not  a  disease.  The 
homogenistic  acid,  which  is  looked  upon  as  a  basis  of 
the  condition,  is  not  accounted  for  by  any  definite  error 
of  cellular  function.  The  problem  is  unsolved. 

Congenital  jaundice  is  a  similar  condition,  which  is 
recognized  by  the  color  of  the  skin  and  sclera.  The 
clinical  symptoms  of  jaundice  are  not,  however,  pres- 
ent, and  the  subject  is  not  sick.  This  bizarre  manifes- 
tation has  been  troublesome  to  the  bearer  only  from 
the  remarks,  anxiety  and  meddlesome  activities  of  ac- 
quaintances and  medicine  mongers.  A  policeman  with 
congenital  jaundice  has  been  so  much  troubled  by  be- 
nevolently anxious  passers-by  on  his  street  crossing 
that  he  begged  to  be  relieved  of  a  duty  that  made  him 
conspicuous.  Still  the  problem  of  congenital  jaundice 
is  unsolved. 

The  list  of  conditions  which  are  recognized  by  some 
flamboyant  symptom  could  be  greatly  extended.  They 
furnish  a  promising  field  for  chemico-physiologic 
study,  promising  the  most  radical  extension  of  our 
horizon  of  knowledge  and  therapeutic  adventure. 

If  these  conspicuous  errors  of  metabolism,  which 
produce  no  morbidity,  can  be  explained  by  the  disciples 
of  pure  chemical  science,  then  by  the  same  methods 
may  the  etiology  of  myositis  ossificans  and  rhizomelic 
spondylosis  be  solved,  and  the  way  opened  for  cure  or 
prevention.  Our  American  students  who  have  been 
so  successful  in  the  applications  of  physics,  chemistry 
and  biology  in  •engineering,  metallurgy  and  agriculture, 
have  an  untried  field  in  the  diseases  of  uncertain  origin 


MYOSITIS  OSSIFICANS.  /    57 

to  which  we  have  called  brief  attention,  and  by  the 
same  methods  a  great  mass  of  morbidity  and  human 
misery  relieved,  which  we  now  suffer  complacently. 


ALBINISM  IN  ITS  RELATION  TO  MEDICAL 
RESEARCH. 


THE  albino  is  one  of  the  most  conspicuous  of  all  con- 
genital anomalies  consistent  with  life.  It  is  quite  rare 
among  the  European  as  compared  with  some  of  the 
colored  races.  The  negro  is  the  most  subject  to  this 
sport,  and  there  are  albinos  reported  from  the  Congo, 
from  the  Kamarun,  from  Hausaland,  from  the  Sahara, 
from  Madagascar  and  from  Abyssinia.  The  fairer 
Europeans  do  not  give  the  albino  so  striking  a  back- 
ground; nevertheless,  every  nation  and  almost  every 
large  neighborhood  has  an  albino  to  point  to. 

Among  savages  albinos  are  killed  off  the  same  as 
other  defective  infants.  The  Zuni  cliff-dwellers,  how- 
ever, had  in  1896  seven  albinos,  all  but  one  of  whom 
were  adults  (Stevenson,  Twenty-third  Report  Bureau 
of  Ethnology,  1902).  No  two  of  them  were  born  of 
the  same  parents  or  came  from  the  same  family,  and 
none  had  albino  parents.  These  Zunis  were  all  meas- 
ured anthropometrically,  and  the  albinos  stood  high  in 
comparison  with  the  be.st  of  the  tribe. 

Sicily,  which  stands  so  near  Africa,  seems  to  have 
a  large  proportion  of  highly  pigmented  people.  Livi 
(1896)  gives  the  proportion  of  brunettes  to  blondes 
as  3.8  to  2.1  among  the  recruits  from  the  province  of 
Palermo.  In  this  province  Arcoleo  (1871)  found  62 
cases  of  complete  albinism.  They  were  all  born  of 
apparently  normal  parents.  Fifty-nine  albino  children 

59 


60  ESSAYS. 

were  born  into  twenty  families  containing  133  children 
altogether.  (Bateson,  Biometrika,  iii,  pp.  471-2.) 

In  Coahoma  County,  Miss.,  Farabee  observed  a  good 
many  albinos  working  in  the  field  (Science,  1903,  v. 
17,  p.  75).  On  inquiry  he  discovered  that  one  family 
had  four  albino  children.  The  grandfather  of  these 
children  was  an  albino.  He  had  three  perfectly  black 
sons  by  his  normally  black  wife.  Two  of  the  sons 
married  negro  women  and  had  perfectly  black  chil- 
dren. The  other  son  had  two  negro  wives;  by  the 
first  he  had  five  normal  children  and  one  albino,  by 
the  second  he  had  six  normal  children  and  three  al- 
binos. The  albino  children  and  the  other  albinos  in 
the  county  were  the  superiors  in  size  and  appearance 
to  the  blacks. 

Hyde  (1892)  exhibited  before  his  classes  albino 
twins,  born  of  Irish  parents  in  Chicago.  They  were 
healthy,  well-developed  boys. 

Darwin's  classical  observation  of  two  brothers  mar- 
ried to  two  sisters,  their  first  cousins,  none  of  the  four 
nor  any  of  their  families  being  albinos,  must  not  be 
forgotten.  The  seven  children  produced  from  this 
double  marriage  were  every  one  of  them  perfect  al- 
binos. 

Sym  (1891)  observed  a  family  of  seven  children 
that  were  alternately  albino  and  normal. 

Coinde  (quoted  by  Gould  and  Pyle,  1900)  speaks  of 
a  man  who  had  three  albino  children  by  two  different 
wives. 

The  Cape  May  albinos  of  our  grandfathers'  days, 
two  of  whom  were  exhibited  in  Philadelphia  in  the 


ALBINISM.  61 

1830's,  were  the  children  of  perfectly  black  parents. 
The  mother  bore  three  black  and  three  albino  children. 
She  accounted  for  the  first  albino  by  a  fright  she  got, 
at  the  unexpected  sight  of  a  white  horse,  while  carry- 
ing the  child.  When  the  second  albino  appeared  she 
suspected  her  husband  of  some  infidelity.  Peace,  was, 
however,  restored  by  the  appearance  of  the  third  al- 
bino (Marcy,  American  Journal  of  Medical  Sciences^ 
1839,  vol.  24,  p.  517). 

Among  domestic  and  wild  animals  also,  albinism  ap- 
pears. The  selection  and  breeding  of  these  sports  has 
produced  types  that  breed  true.  This  is  most  obvious 
in  white  mice,  white  rats  and  white  rabbits,  that  are 
perfect  albinos,  breeding  true.  Nearly  all  wild  animals 
have  shown  occasional  albinos.  The  sacred  white  ele- 
phant is  presumably  an  albino.  Albino  dogs  are  com- 
mon enough.  Albino  cats,  opossums  (Gould  and  Pyle, 
1894),  bears,  wolves,  skunks,  crows,  blackbirds,  trout 
(Castle,  1908),  carp,  poultry  and  doves  are  either  culti- 
vated, exhibited  or  noticed  in  the  scientific  literature. 

The  essential  hereditary  nature  of  albinism  is  shown 
best  by  breeding  albino  mice  and  brown  mice  together. 
By  this  simple  means  Cuenot  (1902)  first  attempted 
to  discover  the  character  of  albinism  and  its  relation 
to  the  Mendelian  law.  When  he  crossed  albino  with 
brown  mice  the  hybrids  were  all  brown ;  the  albinism 
had  entirely  disappeared.  He  predicted  that  the  next 
generation,  breeding  hybrid  with  hybrid,  would  be  one- 
fourth  albino  and  three  fourths  brown.  This  was 
quantitatively  though  not  numerically  the  case.  Then 
his  work  became  clouded  by  unpredicted  experiences. 


62  ESSAYS. 

Darbishire  (1904),  von  Guaite  (1898)  and  Haacke 
(1905)  conducted  similar  experiments  with  almost  sim- 
ilar (except  in  case  of  von  Guaite)  confusion  of  re- 
sults and  conclusions.  It  remained  for  Castle  and 
Allen  (Proc.  Am.  Acad.  of  Arts  and  Scien.,  v.  38,  p. 
603,  1902)  to  elucidate  the  tangle  and  place  the  phe- 
nomena of  albinism  in  accord  with  the  Mendelian  law. 
There  are  certain  experiences  in  the  crossing  of  al- 
binos which  led  to  the  varying  interpretations  now  hap- 
pily explained,  but  they  are  not  pertinent  to  this  es- 
say. Suffice  it  to  say  that,  as  we  supposed,  albinism  is 
a  truly  recessive  character,  and  conforms  in  breeding 
to  the  Mendelian  law.  So  far  as  these  experiments 
are  concerned,  albinism  is  in  the  same  category  as 
other  congenital  malformations  consistent  with  life — 
six  fingers,  for  example. 

The  material  for  the  study  of  albinism  in  man  is 
very  meager. 

1.  No  instance  of   families  in  which  both  parents 
were  albinos  has,  so  far  as  our  researches  show,  been 
recorded. 

2.  No  family  of  one  albino  and  one  normal  parent 
has  ever  had  an  albino  child. 

3.  All  albino  children  have  been  born  of  apparently 
normally  pigmented  parents. 

4.  Only  one  family  of  albino  children  ( Faribee,  1903) 
had  an  albino  grandparent,  and  that  family  was  com- 
posed of  fifteen  children  by  two  different  wives,  of 
which  children  four  were  albinos. 

These  findings  are  perfectly  consistent  with  the  Men- 
delian law.    \Ye  must  still  account  for  the  appearance 


ALBINISM.  63 

of  families  in  which  all  the  children  were  albinos  (Dar- 
win's) and  other  families  in  which  one-half  the  chil- 
dren were  albinos  (Sym,  8). 

Every  case  of  albinism  ought  to  be  most  patiently 
studied  whenever  it  occurs.  Gunn,  A.  R.  (Lancet,  1907, 
vol.  i,  p.  908).  appeals  to  English  physicians  to  allow 
him  to  study  the  genealogy  of  albinos  that  they  may 
recognize.  In  America  there  is  a  mixed  population 
which  ought  to  furnish  an  unusually  rich  field  for  this 
study,  and  the  local  practitioner  can  hardly  offer  a 
more  welcome  contribution  than  an  extended  geneal- 
ogy of  a  family  in  which  albinism  has  appeared.  In 
Mississippi,  where  the  negroes  are  tainted  with  albin- 
ism, an  unusual  opportunity  presents  to  add  materially 
to  our  knowledge  of  heredity.  It  is  by  such  means  and 
such  publications  that  the  confused  ideas  held  by  many 
medical  men  will  at  last  be  cleared  up. 

Senility  is  ostentationsly  marked  by  the  disappear- 
ance of  pigment  in  the  hair  and  skin.  Many  imbeciles 
are  prematurely  gray.  There  is  a  high  percentage  of 
albinism  of  the  retina  among  the  insane.  Is  there  also 
an  absence  of  pigment  in  the  brain  of  the  senile,  in  the 
insane  and  in  the  feeble-minded? 

The  frequent  association  of  albinism  and  deafness 
in  cats,  and  the  appearance  in  the  same  individual  of 
deaf-mutism,  spinning  idiocy  and  albinism  leads  Karl 
Pearson  (1910)  to  consider  the  existence  of  some  caus- 
ative relation  between  them. 

There  are  but  two  cases  of  complete  post-mortem 
examination  of  albinos.  Buzzi  (1783)  and  Adler  and 
Mclntosh  (1910).  Buzzi  was  too  early  for  histologic 


64  ESSAYS. 

examination.  In  Adler  and  Mclntosh's  case  the  brain, 
the  internal  ear,  the  sclera,  the  iris,  the  choroid,  the 
skin,  the  hair  and  all  other  parts  of  the  body  were  com- 
pletely devoid  of  pigment. 

There  is  still  one  view  of  albinism  which  deserves 
consideration.  Cuenot,  from  some  experiments  which 
he  contrived,  was  led  to  believe  that  the  pigmentation 
of  the  body  was  due  to  a  chromogen  and  a  ferment, 
and  that  albinism  resulted  from  the  absence  of  either. 
Mudge  (Journal  of  Physiology,  vol.  38,  p.  67)  says 
Miss  Durham  has  extracted  from  the  skin  of  young 
animals  a  substance  which,  when  incubated  with  tyro- 
sin  to  which  a  small  quantity  of  ferrous  sulphate  is 
added  to  act  as  an  activator,  throws  down  a  pigmentary 
substance  corresponding  to  the  color  of  the  animal. 
Durham  also  finds  a  ferment  in  the  skin,  which  she 
calls  tyrosinase,  which  produces  a  pigment  when  acting 
on  tyrosin.  Arguing  that  fermentation  is  an  oxidation 
or  reduction,  and  assuming  that  the  skin  of  the  albino 
does  contain  a  chromogenous  body  which  only  needs  an 
oxidizing  body  to  change  it  into  a  visible  pigment, 
Mudge  placed  white  rats  in  a  10  per  cent,  formalin  so- 
lution of  70  per  cent,  alcohol,  and  developed  in  the  hair 
a  vivid  yellow,  which  became  brown  in  a  bath  of  H2O2 
at  the  end  of  twenty- four  hours.  The  same  process 
produced  analogous  results  with  white  mice.  (Ibid, 
1909,  p.  17.) 

This  experiment  is  very  suggestive,  at  least.  In 
myositis  ossificans  progressiva  we  have  a  congenital 
condition  apparently  of  a  chemical  nature  (a  meta- 
bolipathy  which  is  so  rare  and  disastrous  to  life  that 


ALBINISM.  65 

procreation  and  transmission  -are  unrecorded.  Con- 
genital jaundice  is  another  harmless  but  conspicuous 
condition  in  the  same  category.  Alkaptonuria  is  still 
another.  In  hemophilia  a  congenital  error  of  a  biologic 
and  chemical  nature  is  manifest,  which,  on  account  of 
its  dramatic  manifestation  (hemorrhage),  has  been 
long  and  well  studied  in  its  clinical  features,  and  is 
now  claiming  the  energy  of  the  new  chemistry.  It  is 
to  urge  the  extension  of  the  same  methods  to  other 
congenital  conditions  that  this  essay  is  written. 

Even  the  possibility  of  a  therapeusis  for  congenital 
conditions  like  myositis  ossificans,  albinism  and  hemo- 
philia should  not  be  despaired  of  by  the  prophets  in 
this  captivity  of  modern  pessimism  and  therapeutic 
nihilism.  The  late  J.  Nevins  Hyde  (1892),  when  he 
exhibited  twin  Irish  albino  boys  in  his  clinic,  sug- 
gested the  transfusion  of  blood  from  pigmented  per- 
sons. It  may  be  that  the  negro  has  a  larger  increment 
of  the  pigment  ferment  in  his  blood,  and  that  it  could 
be  utilized. 

The  artificial  or  acquired  leukodermas  furnish  auxil- 
iary material  for  study  in  this  connection,  and  cannot 
be  neglected.  The  leukoderma  of  arsenic  poisoning  is 
evidence  of  localized  chemical  action. 

A  great  mass  of  the  literature  of  albinism  is  found 
in  the  ophthalmic  serials,  but  the  specialist  has  been 
overattentive  to  the  eye,  which  suffers  most  from  the 
absence  of  the  choroid  pigment. 

No  congenital  anomaly  lends  itself  so  readily  to  the 
conditions  of  laboratory  experimentation  and  obser- 


66  ESSAYS. 

vation  as  albinism,  and  its  study  can  hardly  fail  to 
yield  unforseeable  educational,  eugenistic  and  thera- 
peutic fruits  in  due  season. 


THE  EXPLOITATION  OF  THE  MYSTICAL 
IN  MEDICINE. 


IT  is  not  often  that  a  more  subtly  pernicious  article 
appears  in  the  lay  press  than  one  in  the  Ladies'  Home 
Journal  of  October,  by  a  Baptist  minister  who  has  an 
unusual  command  of  language  and  rhetoric.  He  told 
how  he  was  hit  on  the  head  and  suffered  concussion 
of  the  brain  of  only  a  few  hours'  duration,  and  then 
came  out  of  a  "dual  state,"  which  made  it  necessary 
for  him  to  learn  over  again  all  physical,  mental  and 
spiritual  things,  but  gave  him  at  the  same  time  the 
power  to  learn  with  a  celerity  unequalled  by  anything 
in  his  or  our  experience.  After  he  had  learned  an  in- 
definite number  of  languages,  spending  only  a  few 
hours  at  each,  as  the  normal  child  spends  only  a  few 
months  at  each,  he  with  great  labor  (obstetric,  not  eco- 
nomic significance  of  this  word)  brought  himself  back 
into  his  normal  personality,  in  which,  he  asserts,  he 
has  uninterruptedly  remained  ever  since! 

To  us  it  is  one  of  those  cases  of  hysteria  following 
head  injury,  which  was  referred  to  as  exceptional  by 
us  in  our  paper  on  "Mental  Aberration  Following  In- 
juries of  the  Head,"  which  was  read  November  22 
before  the  American  Association  of  Railway  Sur- 
geons in  Chicago.  It  is  a  curious  misconception  in 
the  lay  mind  that  insanity  follows  injuries  of  the 
head.  It  does,  but  in  so  small  a  proportion  of  cases 
that  it  must  be  looked  upon  as  a  precipitating  event 

67 


68  ESSAYS. 

rather  than  an  adequate  cause.  One  out  of  every  four 
hundred  citizens  is  eventually  declared  insane.  Not 
one  out  of  fifty  of  the  population  of  our  insane  asylums 
gives  any  history  of  injury  of  the  head. 

Concussion  of  the  brain  is  often  followed  by  hysteria, 
which  in  the  case  of  our  Baptist  minister  approached 
a  grave  condition.  He  appears  to  us  to  be  not  far  re- 
removed  from  many  other  cases  to  be  found  recorded 
in  the  medical  literature.  In  the  article  referred  to 
we  recited  one  case  marvelously  cured  by  our  sugges- 
tion. Clarke1,  Janet2  and  Amselle3  give  numerous  cases 
illustrating  at  once  the  various  traumatic  sources  of 
hysteria,  and  especially  the  forms  of  hysteria  follow- 
ing immediately  on  concussion  of  the  brain.  The  close 
relation  between  epilepsy,  hysteria  and  insanity,  and 
the  uniformity  with  which  a  great  trauma  brings  these 
hidden  conditions  into  evidence,  is  abundantly  illus- 
trated in  these  books. 

Injuries  of  the  head  are  followed  by  disturbance  of 
cerebration,  sometimes  apparently  productive  of  good 
sense,  but  generally  of  the  contrary  condition.  The 
habit  of  railway  claim  agents  in  securing  release  papers 
from  injured  passengers  and  employees  at  such  times 
is  distinctly  unethical  and  would  not  be  smiled  upon 
by  an  enlightened  judiciary.  The  "specialist,"  e.g., 
the  alienist,  is  at  a  distinct  disadvantage  in  the  short 

1  Clarke :  "Hysterics  and  Neurasthenics."  John  Lane.  Lon- 
don and  New  York,  1904,  8vo,  pp.  298,  v.  247-260. 

2  Janet :  "The  Major  Symptoms  of  Hysteria."  MacMillan 
Co.,  London  and  New  York,  1907,  8vo,  pp.  345,  v.  138-159. 

3  Amselle :    "Conception    de    1'Hysterie."     O.    Doin,    Paris, 
1907,  8vo,  pp.  297.    V.  Bibliograph,'  pp.  287-297. 


EXPLOITATION  OF  THE  MYSTICAL  69 

time  he  has  his  patient  under  observation.  The  sur- 
geon who  finds  an  insane,  an  epileptic  or  a  hysterical 
patient  who  has  passed  into  one  of  these  conditions 
after  an  injury  of  the  head,  is  too  apt  to  look  upon 
the  trauma  as  an  adequate  cause,  and  seek  to  cure  the 
disease  by  the  almost  sacerdotal  trephine.  In  the  furor 
operandi  of  the  last  quarter  of  a  century  many  wounds 
of  heads  were  made,  which  heads  are  now  found  in  the 
institutions  for  the  epileptics  and  for  the  insane,  and 
soon  will  be  preserved  in  our  burial  grounds,  to  the 
great  confusion  and  wonder  of  the  archeologists  of 
the  future  society  which  may  arise  after  our  civiliza- 
tion and  its  literature  are  destroyed. 

But  the  greatest  lesson  to  be  learned  from  the  little 
minister's  autobiography  in  Mr.  Bok's  popular  paper 
is  the  insatiable  hunger  and  thirst  of  his  readers  for 
the  mystical  and  the  mysterious  in  human  life.  If  he 
had  been  cured  by  Swamp  Root,  the  little  minister's 
testimonial  would  not  have  been  half  as  pernicious, 
though  perhaps  twice  as  remunerative.  However,  the 
audience  that  takes  to  all  manner  of  pseudo-sciences, 
such  as  the  "conquest  of  cancer,"  "eugenics,"  "Fletch- 
erism,"  "Kneip's  nature  cure,'*  "Christian  science"  and 
"Emmanuel  movements,"  will  be  further  confirmed  in 
their  belief  in  the  superscientific  by  this  artistic  bit  of 
pathological  romance. 

In  these  times  let  us  suggest  that  every  doctor  add 
to  his  litany  the  following  invocation :  "From  all  inex- 
plicable psychological  manifestations  simulating  dis- 
ease, which  befall  our  patients ;  from  all  unreasonable, 
mysterious  and  mystical,  though  entertaining  and  in- 


70  ESSAYS. 

spiring,  theories  of  cure,  whether  attended  by  a  pitiable 
paucity  of  poor  and  ignorant  followers  or  by  a  mag- 
nificent scintillation  of  moving  masses  of  gorgeously 
bejeweled  pageantry,  good  Lord  deliver  us." 


THE  FEEBLEMINDED. 


IDIOCY  is  so  terrible  an  affliction  that  it  has  from 
earliest  times  had  legal  and  social  recognition.  It  is 
due  to  one  of  two  causes,  a  germinal  variation  on  the 
one  hand,  and  a  bodily  modification  on  the  other.  In 
the  former  case,  it  is  inherent  in  nature,  hereditary  and 
conceivably  transmissible;  in  the  latter,  it  is  nurtural 
and  no  more  significant  phylogenetically  than  a  broken 
bone. 

Fortunately,  the  great  bulk  of  the  congenital  idiots 
die  at  birth  or  during  the  mortality  of  the  first  weeks 
of  life  usually  from  other  congenital  defects,  and  the 
small  number  remaining  are  segregated  and  prevented 
thereby  from  any  possibility  of  reproduction.  The 
early  death  of  the  congenital  idiot  and  even  the  idiot 
from  the  result  of  disease  or  accident  is  apt  to  occur, 
before  the  suspicion  even  of  the  family  is  aroused  by 
the  tardy  mental  development.  In  the  tremendous 
mortality  of  infants  during  the  first  weeks  of  life  the 
exact  proportion  of  potential  idiots  has  not  been  de- 
termined. 

It  is,  however,  quite  another  condition  which  is 
termed  feeblemindedness.  In  a  primitive  state  of 
society  this  condition  would  not  be  so  serious  a  handi- 
cap. It  is  not  always  attended  by  feebleness  of  body. 
It  is  a  condition  both  of  germinal  variation  and,  there- 
fore, transmissible  by  the  Mendelian  law,  and  of  acci- 
dental bodily  modification  and  non-transmissible.  This' 
condition,  which  is  the  result  of  congenital  malforma- 

71 


72  ESS  A  YS. 

tion,  on  the  one  hand,  and  of  disease  or  injury  on  the 
other,  known  as  feeblemindedness,  finds  only  tardy 
recognition  in  the  monuments  of  philanthropy  and  the 
annals  of  our  statute  books.  The  word  feebleminded 
itself,  with  its  technical  meaning,  is  of  so  recent  use 
that  the  more  pedantic  place  a  hyphen  after  the  ad- 
jective portion  to  separate  it  from,  rather  than  connect 
it  to,  the  substantive  part.  Indeed,  we  may  search  the 
statute  books  in  vain  to  find  what  provisions  have  been 
legally  made  to  guide  the  courts  in  their  conduct  to- 
ward this  growing  class  of  citizens.  In  a  few  instances 
a  finical  legislature  has  used  the  word  feebleminded  as 
synonymous  with  idiot  when  framing  the  title  of  its 
laws,  but  an  analysis  of  the  subjoined  statute  discloses 
a  failure  to  consider  the  feebleminded,  properly  speak- 
ii.g,  at  all. 

The  feebleminded  embrace  that  class  of  the  com- 
munity deficient  in  intellect,  but  not  idiotic,  deluded  or 
epileptic  and  not  subject  to  commitment  or  any  legal 
restraint  or  recognition.  They  are  capable  of  pro- 
ductive occupation,  but  are  unable  to  hold  their  own 
under  competition.  They  lack  judgment. 

This  feeblemindedness  is  sometimes  the  result  of 
injury  or  disease  or  of  improper,  injurious  and  de- 
structive treatment,  or  neglect  of  treatment  for  injury 
or  disease;  of  defective  or  deficient  feeding  and 
housing;  of  the  destructive  workings  of  the  factory 
system  or  of  child  labor;  and  of  the  ravages  of  the 
social  evil  and  its  attendant  dissipations.  In  so  far  as 
feeblemindedness  is  the  result  of  post-natal  causes,  it  is 
an  accidental  defect  or  bodily  modification  of  no  more 


THE  FEEBLEMINDED.  73 

phylogenetic  significance  than  the  loss  of  an  arm  or  a 
leg.  Scarcely  a  fanatical  advocate  of  the  hereditary 
origin  of  every  disease,  from  albuminuria  and  appendi- 
citis to  the  "yellows"  and  zoster,  can  be  found  who 
would  legally  inhibit  procreation  on  account  of  the 
fear  that  a  parent  would  convey  to  his  offspring  an 
amputated  extremity  or  a  gold-crowned  tooth.  Even 
those  cases  of  feeblemindedness  in  which  the  Wasser- 
mann  reaction  shows  a  syphilitic  pre-natal  basis  are 
only  transmissible  so  far  as  syphilis  is  transmissible  to 
the  offspring,  and  the  child  of  such  a  feebleminded 
parent  is  no  more  likely  to  be  feebleminded  than  he  is 
to  have  a  syphilitic  bone  or  hepatic  gumma.  It  is  still 
too  early  to  learn  the  benefits  of  treatment  of  heredi- 
tary syphilis,  discovered  in  the  first  weeks  of  life  by 
hemolytic  reaction,  in  preventing  the  baneful  effects  of 
this  disease  on  the  cerebrospinal  system. 

Just  how  large  a  portion  of  the  feebleminded  are  in 
this  unhappy  and,  to  us,  shameful  condition  as  the 
result  of  post-natal  accident,  starvation  and  abuse,  or 
of  other  non-transmissible  causes  such  as  hereditary 
syphilis,  tuberculosis  or  ancylostomasis  no  commission 
has  ever  attempted  to  determine.  We  may  safely  and 
inclisptttably  affirm  that  in  so  far  as  infants  are  prop- 
erly fed  and  cholera  infantum  prevented;  in  so  far  as 
the  epidemics  of  the  acute  infectious  diseases  are  lim- 
ited or  arrested,  and  the  sick  of  these  diseases  so 
rationally  treated  as  to  prevent  the  onset  of  dangerous 
complications  and  mixed  infections ;  in  so  far  as  child- 
hood is  protected  from  the  piratical  manufacturers'  re- 
lentless machinery  and  inhuman  toil,  the  benumbed  and 


74  ESSAYS. 

paralyzed  condition  of  mind  which  we  term  feeble- 
mindedness will  be  proportionally  diminished. 

There  is  a  renlnant  of  the  feebleminded  that  is  such 
from  congenital  defect.  They  are  not  "inferior  mem- 
bers of  a  normal  mankind."  "They  suffer  from  a  de- 
ficiency of  mind,  a  failure  of  mental  development, 
which  is  of  precisely  the  same  kind  as  and  merely 
differs  in  degree  from  the  states  of  imbecility  and 
idiocy."  Although  this  lamentable  condition  may  be 
ameliorated  it  can  never  be  cured,  and  such  feeble- 
minded person  turned  into  a  normal  individual.  It 
may  be  assumed  to  be  an  accidental  variation,  there- 
fore transmissible,  according  to  the  Mendelian  law,  to 
succeeding  generations.  In  these  congenitally  de- 
formed, procreative  power  and  sexual  pertinacity 
seem  to  be  early  and  irresistibly  developed.  A.  F. 
Tredgold  has  found  such  feebleminded  are  actually, 
even  under  the  unfavorable  surroundings  of  moderr 
economic  restraint,  one  and  a  half  times  more  prolific 
than  the  normally  intelligent.  In  this  way  does  nature 
express  a  determination  to  perpetuate  any  accidental 
variation,  even  though  our  present  judgment  is  that  the 
strain  is  unfit.  Sixteen  feebleminded  mothers  gave 
birth  to  116  children,  and  in  one  family  of  fourteen 
only  four  were  able  to  do  remunerative  work. 

In  the  rush  and  hustle  of  our  American  business 
and  professional  life,  there  is  little  time  for  that 
wisdom  that  comes  from  contemplation.  The  doctor 
of  medicine  must,  however,  take  a  hunch  of  the  times 
and  wake  up  to  the  surroundings  which  are  leaving 
a  heritage  of  woe  to  the  coming  generation.  The 


THE  FEEBLEMINDED.  75 

sacrifice  of  our  forests,  our  public  domain,  our  water 
power  and  our  mineral  resources  by  extravagant  and 
ruinous  exploitation  at  the  hands  of  organized  com- 
mercial bandits  and  pirates  is  not  more  hazardous 
to  the  happiness  of  the  next  generation  than  the 
neglect  of  the  orphan,  the  feebleminded  and  the  other 
defectives. 

It  is  the  duty  of  the  -economist  citizen  to  furnish 
a  conscience  to  the  State  in  its  relation  to  fuel,  lum- 
ber, water  and  transportation,  and  it  is  an  equally  im- 
minent duty  of  the  doctor  to  warn  against  the  danger 
that  the  State  may  lose  that  grand  resource  for  which 
all  others  are  conserved,  namely,  a  vigorous  and  un- 
blemished citizen  body.  To  do  this  he  must  combine 
the  most  intimate  and  familiar  knowledge  of  the  ex- 
act sciences  and  a  healthy  experience  in  the  affairs 
of  State,  village  and  family.  Fortunately,  in  the  many 
aids  to  knowledge  and  culture  which  libraries,  journals 
and  monographs  now  afford,  such  a  near-Utopian  con- 
dition is  possible.  The  whole  subject  of  heredity  is 
presented  in  a  perfectly  readable  and  intensely  fasci- 
nating manner  by  J.  Arthur  Thompson  in  his  book  of 
that  name  (G.  P.  Putnam's  Sons,  1908),  and  the  eight 
blue  books  of  the  Royal  Commission  are  now  at  hand 
and  give  a  detail  of  information  of  world-wide  condi- 
tions which  deserves  the  attention  of  every  good  citi- 
zen doctor. 

It  appears  that  the  ratio  of  feebleminded  to  the  nor- 
mal is  about  1  to  120.  In  every  school  of  1,200  pupils 
there  are  at  least  ten  feebleminded  children;  in  every 
city  of  120,000  inhabitants  there  are  1,000  feeble- 


76  ESSAYS. 

minded  citizens ;  in  this  great  nation  of  nearly  one 
hundred  million  people  there  are  nearly  830,000  per- 
sons ''who  arc  capable  of  earning  a  living  under  favor- 
able circumstances,  but  are  incapable,  from  mental  de- 
fect existing  from  birth  or  early  age,  of  competing  on 
equal  terms  with  their  normal  fellows  or  managing 
themselves  and  their  affairs  with  ordinary  prudence."1- 

Like  any  machine  of  human  construction,  the  law  re- 
quires to  be  fed  with  a  standardized  product.  In  its 
application,  "a  man's  a  man ;"  the  fact  that  he  is  feeble- 
minded is  not  pertinent.  During  the  last  century  the 
lunatic  has  been  legally  extruded  from  the  hopper  of 
the  courts  by  the  commitment  device.  Xot  so  the  feeble- 
minded. All  students  of  feeblemindedness  recognize 
the  almost  equal  responsibility  of  the  lunatic  and  the 
weakminded.  The  Royal  Commission  found  that  20 
per  cent,  of  the  criminal  population  of  Great  Britain 
were  mentally  defective,  and  at  least  10  per  cent,  of  the 
tramps  were  feebleminded.  Almost  half  of  the  girls 
in-  the  brothels  were  feebleminded,  and  some  were  al- 
most idiots.  Yet  in  the  workhouse  these  women  were 
very  prolific,  and  even  when  married  their  sexual  over- 
development was  so  great  that  more  than  half  of  them 
"led  immoral  lives."  One  hundred  and  fifty  pairs  pro- 
duced at  least  328  offspring  definitely  diseased  in  mind 
or  body.  The  cost  of  each  feebleminded  person  to  the 
commonwealth  was  estimated  by  the  commission  at 
about  $10,000. 

One  of  our  first  duties  is  to  inform  the  public 
of  the  condition  of  feeblemindedness  and  secure 
laws  recognizing  this  state  in  which  1-120  of  our 


THE  FEEBLEMINDED.  77 

population  belong.  The  indulgence  of  the  law  to 
this  class  should  be  legally  vouchsafed  and  the  in- 
human action  of  the  police  toward  feebleminded 
offenders  should  be  stayed  by  statutes.  The  civil 
rights  of  the  feebleminded  should  be  curtailed  and 
a  public  conservator  should  be  provided  in  every 
community  to  protect  them  from  normal  citizens,  or, 
where  economic  conditions  demand,  a  private  con- 
servator should  be  possible.  Those  feebleminded  who 
are  such  from  prenatal,  transmissible  causes  should  be 
segregated  permanently  and  procreation  should  be 
prevented.  This  is  especially  necessary  in  the  case  of 
feebleminded  girls  whose  only  avenue  of  self-support 
is  the  red  light  road. 

There  are  good  reasons  why  all  the  feebleminded 
should  be  treated  with  the  greatest  consideration  and 
almost  worshipful  gentleness.  The  elimination  of 
some  phases  of  intellect  exposes  the  emotions,  the 
passions  and  even  that  mystery,  the  imagination,  to 
unexampled  prominence.  As  we  learn  from  compara- 
tive anatomy  and  physiology,  so  we  should  learn  from 
these  adult  children.  Such  was  Darius  Green  of  the 
flying  machine,  a  prophet  of  the  Wright  brothers' 
aeroplane.  The  spirit  of  St.  Francis  of  Assisi  was 
exhibited  for  the  world's  admiration  and  edification 
by  a  feebleminded  man  "who  was  incapable  of  man- 
aging himself  and  his  affairs  with  ordinary  prudence.'' 
The  spirit  of  modern  child  study  and  fundamental 
education  has  been  largely  assisted  by  the  study  of  the 
mental  processes  of  the  feebleminded.  Every  person 
who  has  had  to  do  with  the  feebleminded  is  dull  indeed 


78  ESSAYS. 

if  his  spirit  is  not  ripened  and  mollified  by  the  experi- 
ence. 

The  trades  unions  should  become  thoroughly  in- 
formed of  the  significance  of  feeblemindedness  to  the 
labor  problem.  In  the  labor  market  the  feebleminded 
are  ever  at  the  mercy  of  "the  meanest  employer."  The 
fact  of  feeblemindedness  does  not  interfere  with  pro- 
duction in  many  occupations  of  the  modern  industrial 
system.  The  machines  are  made  so  simple  that  any 
fool  can  run  one  and  they  are  made  so  strong  that  no 
fool  can  break  one.  And  it  is  this  army  of  less  than  1 
per  cent,  of  laborers  that  capital  uses  to  break  each 
succeeding  strike.  \Yithout  the  wit  to  protect  them- 
selves they  are  collected  from  hither  and  yon  and  when 
the  strike  is  over  they  are  thrown  out  for  better  men. 

The  Royal  Commission  estimated  that  each  feeble- 
minded person  cost  the  State  sooner  or  later,  and 
before  he  was  under  ground,  not  less  than  $10,000. 
In  the  whole  United  States  this  means  a  good  round 
sum,  enough  to  build  a  battleship  or  endow  a  uni- 
versity or  even  a  medical  school  now  and  then. 
Capital,  so  prone  to  protect  itself,  should  protect  itself 
from  taxation  for  this  item  of  the  annual  budget. 
These  defectives  are  capable  of  productive  labor,  but 
incapable  of  playing  the  game  called  "the  competitive 
system."  Those  who  fear  the  coming  of  Socialism 
should  stay  the  grind  and  squeak  of  competition  by 
caring  for  this  disturbing  element. 

Educators  have  already  demanded  and  secured 
separate  schools  for  backward  children.  When  the 
backwardness  is  due  to  peripheral  defects  in  carrying 


THE  FEEBLEMINDED.  79 

communications  to  and  from  a  normal  brain,  the 
teachers  have  done  wonders.  They  must  not,  how- 
ever, be  required  or  expected  to  accomplish  the  miracle 
of  making  the  feebleminded  strongminded  or  normal. 
Helen  Keller  had  an  imprisoned  normal  mind  of  great 
alertness.  Her  education  was  simply  a  process  of 
opening  doors.  Each  State  has  its  lielen  Kellers,  and 
some  of  them  are  educated  by  the  liberal  legislative 
appropriations  of  a  prodigal  people.  The  presence  of 
the  feebleminded  in  public  schools  is  embarrassing  to 
the  teacher,  disturbing  to  school  discipline  and  un- 
profitable in  its  results.  The  diagnosis  of  feeble- 
mindedness should  be  made  early  by  the  exclusion  of 
peripheral  retardation  of  apperception,  and  its  etiology 
should  guide  in  the  subsequent  disposition  of  the  un- 
fortunate. Under  proper  guidance,  a  simple  rural  life, 
almost  a  life  of  savagery,  in  its  etymologic  significance, 
would  be  humane,  rational  and  economical,  and  save 
the  police,  the  courts  and  the  philanthropist  much 
futile  activity. 


OUR  LESSON  FROM  THE  HOOKWORM. 


A  MOST  widely  read  and  cultured  physician  expressed 
to  us  the  opinion  that  every  insane  person  was  in  his 
dilemma  by  the  natural  result  of  his  own  unreasonable 
ideas  and  the  reasonable  conduct  following  the  enter- 
tainment of  those  ideas.  He  expressed  the  utmost 
horror  at  any  association  with  these  miserable  crea- 
tures, and  pooh-poohed  the  notion  that  any  intoxica- 
tion or  other  "somatic"  cause  lay  at  the  bottom  of  the 
insanities.  After  considerable  argument  he  reluctantly 
allowed  that  alcoholism  precipitated  delirium  tremens 
and  some  cases  of  so-called  alcoholic  insanity;  that 
syphilis  or  alcoholism  or  both  preceded  most  cases  of 
general  paresis ;  that  pregnancy  and  parturition  were 
the  antecedents  of  puerperal  insanity,  and  that  certain 
poisons  seemed  to  initiate  insanity  in  a  few  individuals  ; 
but  that  the  bulk  of  the  insane  went  "batty"  because 
they  entertained  irrational  or  twisted  ideas. 

It  was  a  distinct  shock  to  us  to  find  so  medieval  a 
philosophy  in  such  a  representative  person.  All  our 
education  since  Newton,  Boyle,  Tyndall,  Darwin,  Koch 
and  Ehrlich  began  to  influence  medicine,  has  been  to- 
ward the  rational,  the  natural  and  the  consequential 
cause  of  all  phenomena,  making  no  exception  of  those 
of  the  human  mind.  We  find,  however,  that  the  mala- 
dies of  more  than  two  hundred  thousand  of  our  fel- 
low citizens  are  placed  by  a  most  respectable  and  influ- 
ential portion  of  the  medical  fraternity  to  the  credit, 
not  of  the  devil  ("possessed  of  a  devil"),  not  of  the 

81 


82  ESS  A  YS. 

moon  ("lunatic"),  but  to  the  credit  of  the  twisted  idea. 

If  one  will  try  and  put  himself  in  the  other's  place 
and  learn,  it  may  be  possible  that  we  can  agree. 

Some  of  our  leaders  in  the  custody  of  the  insane  in- 
sist that  unless  we  acknowledge  the  boundary  between 
mental  and  physical  disease,  and  can  distinctly  limit 
each,  we  are  hopelessly  out  of  all  consideration  and 
beyond  the  jurisdiction  of  reason.  (Mercier,  Journal 
of  Mental  Sciences,  July,  1910,  p.  407  ad  fin.) 

Mercier  elsewhere  insists  as  if  it  was  an  acknowl- 
edged fact  that  "insanity  is  a  disorder  of  the  mind" 
(loc.  cit.,  p.  408,  line  22),  and  then  modifies  the  as- 
sumed general  consensus  of  opinion  by  contending  that 
"insanity  is  a  disorder  not  alone  of  mind  but  of  con- 
duct" (loc.  cit.,  p.  409,  line  6,  also  lines  15  and  35). 
This  same  authority,  who  represents  the  conservative 
and  satisfied  alienists  as  well  as  any  single  man  that 
we  can  pick  out,  further  says :  "The  universe  of  matter 
and  motion  lies  on  one  side  of  a  gulf,  and  the  universe 
of  mind  lies  on  the  other.  The  gulf  is  bottomless,  and 
its  width  and  length  stretch  to  infinity"  (loc.  cit.,  p. 
411,  lines  30-32). 

To  us  no  more  senseless,  mystical  and  unscientific 
statement  can  be  imagined  than  this,  but  as  it  wrent 
unchallenged  before  a  body  of  English  alienists  who 
showed  themselves  quite  free  to  criticize  the  author 
in  many  other  directions,  it  is  likely  that  it  coincided 
with  the  opinion  of  those  who  attended  the  meeting  of 
the  Medico-Psychological  Association  of  Great  Britain 
and  Ireland,  in  London,  May  24,  1910.  In  other  words, 
we  must  accept  the  apparent  fact  that  those  most  in- 


LESSON  FROM    THE   HOOKWORM.  83 

timate  with  the  insane,  and  those  who  profess  to  have 
studied  the  problems  of  the  insane  from  every  stand- 
point and  in  a  scientific  manner,  assert  that  one  side 
we  have  the  body  and  all  its  diseases,  and  on  the  other, 
separated  by  an  immeasurable  gulf,  is  the  mind  and  its 
disorders,  among  which  are  the  insanities.  This  is  the 
line  of  battle  to-day. 

The  great  bulk  of  the  medical  profession  and  all  the 
laity  have  scant  opportunity  to  observe  the  insane.  By 
the  unanimous  custom  of  modern  society,  at  the  first 
evidence  of  mental  aberration  the  patient  is  haled  be- 
fore a  court,  declared  a  lunatic  and  placed  in  a  hopeless 
custody.  The  legal  proceedings  are  similar  to  criminal 
proceedings,  except  for  the  most  part  there  is  no  devil's 
advocate.  This  method  also  adds  to  the  terror-breed- 
ing associations  of  the  insanities  in  the  mind  of  the 
common  people. 

When  one  undertakes  to  support  by  argument  a 
proposition  that  he  considers  axiomatic  he  is  in  a  very 
unfortunate  position.  We  sympathize  with  him  now. 
To  us  there  is  no  mind  separate  from  the  body.  We 
see  the  mind  deranged  by  alcohol,  by  typhoid,  by  syph- 
ilis and  alcohol,  and  by  old  age,  acting,  as  we  believe, 
on  the  body.  It  seems  to  us  that  other  aberrations  of 
mind  are  likewise  the  result  of  bodily  disorders.  The 
fact  that  such  is  the  case  has  perhaps  not  yet  been 
demonstrated.  It  is,  however,  easier  for  us  to  look 
forward  to  a  future  demonstration  than  to  change  our 
conception  of  the  unity  of  the  whole  system  of  nature 
and  separate  mind  from  matter  by  an  impassable  gulf. 

We  console  ourselves  in  our  lack  of  argument  by  the 


84  ESSAYS. 

accumulating  evidence  that  the  insanities  are  of  toxic 
origin.  Even  neurasthenia  is  coming  into  the  fold 
of  tangible,  somatic,  demonstrable  physical  diseases. 
(Page,  M.,  Lc  to.vcmie  ueurasthenique,  Paris,  1910, 
octavo,  p.  256.) 

One  by  one  the  mysterious  diseases  of  the  nervous 
system  are  discovering  their  complete  simplicity  on  the 
interrogations  of  relentless  experimental  and  clinical 
methods.  Cerebro-spinal  meningitis  furnishes  not  only 
its  own  solution,  but  its  own  cure.  Infantile  paralysis 
has  at  least  discovered  its  infectious  nature,  and  soon 
its  mastery  by  science  will  surely  be  brought  about. 

In  this  connection  the  recent  study  of  infantilism  by 
Lemann  (Arch,  of  Inter.  Med.,  August  15,  1910),  has 
interested  us  much.  The  patient  under  examination 
was  a  boy,  twenty-two  years  old,  that  contracted  hook- 
worm disease  when  an  infant  and  never  developed 
into  manhood.  The  pubic  hair  and  peculiar  skin  so 
characteristic  of  maturity  were  absent,  and  the  X-ray 
showed  an  equally  infantile  condition  of  the  skeleton 
itself.  Unfortunately,  the  investigator  paid  little  at- 
tentnon  to  the  mental  condition.  The  mind  should 
mature  with  the  body  and  remain  childish  with  the 
child's  body.  Not  until  one  becomes  a  man  does  he 
put  away  childish  things. 

The  intimate  relation  between  the  mental  and  phys- 
ical condition  of  patients  suffering  from  hookworms 
was  early  and  often  pointed  out.  Greene's  classical 
studies  of  the  condition  of  the  insane  in  Florida  puts 
another  question  to  us :  "Does  hookworm  toxemia  pro- 
duce any  of  the  insanities,  and  are  recoveries  possible 


LESSON  FROM   THE   HOOKWORM.  85 

when  the  parasites  have  been  driven  off?"  This  ques- 
tion has  received  an  answer  in  the  report  by  Austre- 
gesilo  and  Gotuzzo  (Arch.  f.  ScJiiff.  u.  Tropenhyg., 
vol.  13,  p.  339)  of  three  cases  of  insanity  that  recov- 
ered as  soon  as  the  thymol  therapy  had  been  success- 
fully applied.  The  authors  express  themselves  posi- 
tively as  believing  the  mental  aberrations  were  caused 
by  the  worms,  that  they  were  symptomatically  cases  of 
insanity,  and  that  they  recovered  with  the  expulsion  of 
the  worms  and  on  that  account  alone. 

\\'e  should  like  to  know  just  how  thoroughly  the 
hookworms  have  been  eradicated  from  the  hospitals 
for  the  insane  in  the  South,  and  how  many  recoveries 
of  the  insanities  have  resulted.  The  fact  that  one-third 
or  more  of  the  insane  harbor  hookworms  in  all  the 
Southern  hospitals  for  the  insane  means  little  when 
we  are  reminded  that  probably  at  least  one- fourth  of 
the  well-to-do  citizens  of  the  South  are  infected.  Gage 
and  Bass  (Archives  of  Internal  Medicine,  vol.  6,  p. 
301  )  showed  that  medical  students  in  New  Orleans 
were  infected  to  at  least  that  extent,  and  that  one-third 
the  students  residing  in  New  Orleans  harbored  the 
parasite. 

The  old-fashioned  madhouses  were  full  of  bedbugs, 
cockroaches  and  rats,  and  the  patients  had  the  itch  and 
other  parasites  every  winter  at  least.  Now  the  hos- 
pitals have  many  patients  with  hookworm  disease, 
pellagra,  and  tuberculosis.  The  hospitals  have  im- 
proved by  the  elimination  of  some  of  their  parasites. 

Our  contention  is  that  the  insanities  are  the  result 


86  ESSAYS. 

of  physical  disorders  which  are  susceptible  to  scientific 
study  and  ultimate  prevention  or  cure. 

In  the  United  States  with  a  population  of  more  than 
80,000,000,  150,151  were  confined  on  December  31, 
1903,  in  asylums  for  the  insane.  The  annual  expense 
to  the  States  was  $21,329,228.41.  These  expenditures 
have  been  minutely  studied  and  analyzed  but  neither 
the  census  office  nor  any  public  officer  has  reported  any 
appropriation  or  expenditure  designed  to  aid  in  the 
discovery  of  the  causes  of  insanity  or  of  its  prevention. 

It  is  our  contention,  not  from  argument  or  reason, 
but  from  analogy  and  the  irrepressible  credulity  of  the 
human  soul,  and  an  unbounded  confidence  in  the  re- 
sources of  human  ingenuity,  that  the  insanities  are  due 
to  discoverable,  preventable,  even  curable  natural  phys- 
ical causes  and  that  the  least  of  these  is  the  toxemia 
of  the  hookworm. 

The  States  should  maintain  a  laboratory  of  research 
into  the  causes  of  the  insanities.  At  least  5  per  cent. 
of  the  custodial  expenses  should  be  expended  under 
the  direction  of  the  University  in  research.  With  forty 
sovereign  States  and  the  competition  and  rivalry  be- 
tween forty  universities  engaged  in  one  worthy  task 
much  advance  into  the  dark  and  grewsome  continent 
of  our  ignorance  would  surely  eventuate. 

We  have  long  passed  the  stage  of  civilization  in 
which  the  insane  were  hunted  like  wild  beasts,  and 
punished  as  possessed  of  devils  or  caged  and  shackeled 
like  untamable  animals.  Now  we  house  them  gently 
until  they  are  dead,  dead,  dead,  of  the  conditions  and 
diseases  that  result  inevitably  from  our  custody.  How 


LESSONS  FROM  THE  HOOKWORM.  87 

long  will  it  be  before  we  study  our  insane  as  we  study 
other  human  ailments  and  seek  a  cure  as  we  have  suc- 
cessfully sought  in  the  case  of  syphilis  and  diphtheria? 
In  way  of  humility  let  us  give  all  credit  to  the  great 
army  of  alienists  and  humanitarians  who,  under  the 
most  disheartening  opposition,  have  brought  our  mad- 
houses to  a  condition  in  which  we  dare  call  them  hos- 
pitals. They  have  done  a  good  work,  but  it  is  only  a 
beginning.  Now  for  the  sapping  and  mining  of  the 
entrenchments  of  ignorance  of  the  causes  of  the  in- 
sanities, to  the  end  that  they  may,  like  cholera  in- 
fantum,  typhoid  and  smallpox  be  prevented  and  cured 
— a  task  worthy  the  soundest  body,  the  keenest  mind 
and  the  most  embracing  soul. 


THE  LESSON  FROM  VETERINARY  MEDI- 
CINE. 


THERE  are  at  least  two  distinct  methods  by  which 
Brother  Rabbit  and  Brother  Ass  even,  may  help  us 
out  to  solve  the  problems  of  disease  of  obscure  eti- 
ology. At  the  present  time  we  are  looking  intently 
toward  experimental  diseases  of  animals  produced  in 
the  laboratory  and  studied  in  the  test  tube  and  under 
the  microscope.  We  must  not,  however,  forget  the 
greater  sphere  of  possible  analogy  in  the  diseases  of 
animals  as  they  are  discovered  to  the  veterinarian  in 
the  laboratory  for  preventive  animal  disease. 

The  remarkable  utility  of  serologic  diagnostic  meth- 
ods is  happily  illustrated  in  a  few  cases  selected  from 
recent  veterinary  literature.  A  large  number  of  agglu- 
tinative tests  were  made  at  the  pathological  institute  of 
the  veterinary  high  school  in  Berlin,  1907-1908,  and 
elsewhere  in  Prussia,  upon  animals  suspected  of  glan- 
ders. In  one  series,  seventeen  hundred  and  fifty  horses 
were  tested,  of  whom  two  hundred  and  eighty-three 
were  destroyed  or  died ;  one  hundred  and  seventy- 
seven  were  found  at  the  post-mortem  to  suffer  of  glan- 
ders; sixty-nine  were  killed  for  other  reasons. 

The  ease  with  which  the  agglutinative  power  of  the 
blood  can  be  measured  in  animals  and  the  large  number 
of  animals  under  prolonged  observation  make  these 
studies  of  unusual  significance  in  contriving  similar 
methods  for  the  clinics  of  obscure  diseases  of  man. 
The  variation  of  agglutinative  power  in  the  healthy 

89 


90  ESSAYS. 

animal  is  demonstrated  to  be  slow  and  small ;  in  the 
sick,  however,  the  variations  are  tremendous  and  rapid. 
It  was  considered  a  distinct  indication  of  disease  that 
these  peaks  of  variation  appeared  and  they  placed  the 
animals  under  a  suspicion  which  made  more  extensive 
and  exhaustive  study  appear  more  reasonable  to  the 
owners  of  the  studs. 

Agglutinative  tests  have  been  made  in  cattle  of  cer- 
tain districts  affected  with  epidemic  contagious  abor- 
tion. This  disease,  so  disastrous  to  dairy  interests,  can 
be  recognized  afar  off  (five  months)  by  this  method 
and  the  afflicted  animals  can  be  removed  from  chance 
of  infecting  the  herd  and  the  abortion  awaited  under 
conditions  most  favorable  to  the  recovery  of  the  un- 
fortunate animals.  Here  also  the  appearance  of  agglu- 
tination and  its  variation  in  the  same  animal  presents 
material  of  extreme  value  hardly  to  be  looked  for  in 
hospital  and  private  practice  among  human  beings. 
The  long  time  after  the  appearance  of  agglutination 
before  the  obstetric  event  which  infects  the  barn,  the 
yard  or  the  field,  gives  us  hope  for  possible  parallels 
in  human  diseases. 

In  Cape  Colony  cattle  surfer  of  a  peculiar  disease 
known  as  lamziekte.  It  produces  death  by  two  meth- 
ods, an  acute  and  a  chronic  process.  When  acute  the 
animal  quickly  succumbs  to  a  fulminating  infection  and 
the  carcass  swells  up,  the  tissues  give  off  an  unmis- 
takable and  characteristic  odor,  which  has  been  com- 
pared to  that  of  tissues  necrotic  through  extravasation 
of  urine.  In  the  chronic  disease  the  animal  slowly  dies 
of  nervous,  asthenic  manifestations — stiffness,  lame- 


LESSONS  FROM  VETERINARY  MEDICINE.      91 

ness,  trembling,  paralysis  and  other  symptoms  simula- 
ting milk  sickness  so  common  in  the  Mississippi  Valley 
twenty  or  thirty  years  ago.  Strange  enough  this  dis- 
ease made  its  first  appearance  in  Cape  Colony  in  a 
district  which  has  been  noted  for  cattle  raising  for 
many  years.  It  appeared  about  1879  and  gradually 
spread  until  the  herds  were  ruined  and  other  occupa- 
tions and  industries  took  the  place  of  cattle  raising. 
The  herds  are  hardly  able  to  keep  up  their  numbers 
and  many  farms  are  entirely  without  animals.  It  is 
possible  through  the  work  of  William  Robertson  to 
say  that  artificial  immunity  for  this  disease  is  at  hand 
and  that  the  detection  of  the  disease  in  advance  of  its 
onset  has  already  attained  commercial  utility. 

The  acute  infectious  septicemic  disease  of  horses 
known  as  strangles  seems  likely  to  come  under  the  sway 
of  an  artificial  immunity.  Schultz,  in  1888,  discovered 
the  cause  of  this  disease  in  a  streptococcus.  Desouvry 
and  Dassonville  have  recently  evolved  a  serum  or  series 
of  sera  which  they  have  used  in  a  great  number  of 
epidemics  of  strangles  with  increasing  success.  At  the 
present  time  it  is  possible  to  keep  a  stud  in  such  a  con- 
dition that  the  horses  and  colts  will  not  furnish  a  basis 
for  epidemics  of  acute  strangles,  and  susceptible  only 
to  mild  forms  of  the  disease.  In  this  respect  the  con- 
dition is  similar  to  that  of  communities  vaccinated 
against  smallpox.  Sporadic  cases  are  bound  to  occur 
in  unprotected  animals  and  unfortunately  the  sera  have 
so  far  been  found  of  little  avail  in  ameliorating  such 
disease  or  cutting  short  its  course. 

These    illustrations,,  taken  of    a  single  method  and 


92  ESSAYS. 

almost  at  random,  show  how  professional  veterinarians 
have  utilized  serologic  methods  for  diagnosis,  for  pro- 
phylaxis and  for  treatment. 

The  economic  value  of  each  advance  in  diagnosis  is 
guarantee  that  it  will  be  quickly  utilized,  and  the  in- 
creasing value  of  experimental  herds  and  studs  limbers 
up  the  cattle  raising  interests  to  a  liberal  appropriation 
of  money  and  an  acute  economic  recognition  of  tech- 
nical ability.  The  most  valuable  contribution  to  medi- 
cine in  the  United  States  during  the  past  twenty  years 
is  without  any  doubt  the  mastery  of  the  hookworm 
disease.  It  only  awaits  as  vigorous  rational  and  gener- 
ous methods  of  application  of  our  knowledge  to  this 
disease  of  man  as  has  been  applied  to  diseases  of  ani- 
mals in  order  to  open  up  the  empire  of  the  southern 
South  to  as  great  a  prosperity  as  that  which  attended 
the  north  central  States  forty  years  ago. 

To  read  the  literature  of  comparative  medicine  as  it 
comes  forth  from  the  veterinary  laboratories  makes  us 
feel  that  we  are  extravagant  beyond  all  measure  in 
permitting  the  diseases  which  place  two  hundred  thou- 
sand good  citizens  in  the  custody  of  our  madhouses, 
where  they  are  herded  at  great  expense  and  with  a 
devastating  mortality,  without  the  slightest  concerted 
or  sporadic  effort  to  seek  for  the  physical  causes  of  the 
diseases  of  which  insanity  is  the  symptom. 


CYSTINURIA,  DIAMINURIA  AND  ALKA- 
PLONURIA. 


THERE  are  three  derivatives  of  protein  which  are  of 
only  slight  clinical  significance,  but  of  extreme  theo- 
retic and  prophetic  importance.  When  we  read  the 
marvelous  chapter  of  these  strange  manifestations  we 
look  forward  to  analogous  demonstrations  of  symp- 
tom-producing errors  of  metabolism,  the  excretory 
signs  of  which  are  not  yet  recognized  and  associated 
in  our  minds  with  symptoms  which  have  received  clin- 
ical appellations. 

Cystin  is  composed  of  a  combination  of  sulphur  with 
hydro-carbons  and  nitrogen,  and  has  the  complicated 
formula : 

CH2S  —    S  CH2 

CHNH,     CHNH2 

!  I 

COOH       COOH 

This  substance  alone,  of  the  three  here  considered, 
contains  S.  The  diamines  are  much  simpler  in  con- 
struction, and  are  known  as  putrescine,  tetramethylene- 
diamine  and  cadaverine,  pentamethylene-diamine. 

The  alkapton  bodies  are  hydroquinones  or  hydro- 
quinone-acetic  acid.  The  basis  of  these  bodies  is  homo- 
gentistic  acid. 

Clinically,  small  quantities  of  cystin  are  found  in  the 
urine  in  acute  yellow  atrophy  of  the  liver,  phosphorus 
poisoning,  diabetes,  gout,  pneumonia  and  some  other 

93 


94  ESSAYS. 

infections.  But  this  does  not  amount  to  a  cystinuria. 
The  persons  who  have  cystinuria  rarely  make  any  com- 
plaint, and  the  condition  is  accidentally  discovered. 
Six-sided  tables  of  cystin,  which  do  not  dissolve  in 
alcohol,  ether  or  water,  are  found  in  the  alkaline  urine ; 
or,  after  presenting  cystin-bearing  urine  unnoticed  for 
years,  a  calculus  of  cystin  may  make  trouble  anywhere 
in  the  urinary  tract,  from  the  calyx  of  the  kidney  to 
the  meatus.  The  amount  of  cystin  in  the  urine  of 
these  sports  of  metabolism  is  as  much  as  twenty-five 
grains  a  day.  There  is  no  other  evidence  of  the  excre- 
tory error.  Males  and  females  are  about  equally  af- 
fected, and  no  time  of  life  is  exempt.  Even  intra- 
uterine  cystinuria  has  been  observed.  It  seems  to  be 
"in  the  family,"  being  observed  during  three  genera- 
tions, and  in  more  than  one  child  of  the  same  parents. 
Unfortunately,  this  manifestation  has  not  been  studied 
in  the  light  of  the  Mendelian  law.  and  cannot  therefore 
be  pronounced  an  hereditary  and  transmissible  feature. 

Cystinuria  is  a  fleeting  condition,  going  and  coming 
without  known  adequate  cause.  It  frequently  disap- 
pears with  appropriate  diet.  One  would  expect  it  to 
disappear  always  on  a  protein-free  diet.  It  does  not 
always  do  so. 

When  cystin  and  other  monamino-acids  are  taken  by 
normal  persons  by  the  mouth,  they  vanish  as  such  ab- 
solutely, and  no  trace  of  them  is  found  in  the  urine, 
but  when  given  to  the  cystinuric  they  appear  in  the 
urine  unchanged  in  quantity  or  quality. 

The  cystinuric  often  excretes  putrescine  and  cadav- 
erine  in  his  urine  also,  and  these  products  of  bacterial 


CYSTINURIA,  DIAM1NURIA,  ETC.  95 

life  may  be  made  to  disappear  without  any  change  in 
the  cvstinuria.  The  presence  of  these  diamines  is  ir- 
relevant and  negligible. 

The  cystinuric  is  unable  to  completely  dispose  of  his 
proteins  and  eliminate  them  as  urea  and  sulphates  in 
the  urine,  or  to  throw  off  the  sulphur  through  the  bile. 

The  appearance  of  cystin  in  the  urine  in  phosphorous 
poisoning,  and  in  the  analogous  acute  yellow  atrophy, 
has  been  greatly  illuminated  by  experiments  with  halo- 
gens combined  with  the  benzene  radicle.  The  results 
of  these  experiments  seem  to  show  that  cystin  is  a 
product  of  incomplete  metabolism  rather  than  of  any 
bacterial  excretion. 

Diaminuria,  however,  is  evidently  due  to  bacterial 
decomposition  of  proteins.  It  may  also  be  an  error  of 
metabolism.  It  is  a  hydro-carbon  anomaly,  which  clin- 
ically is  often  suspected  by  the  smell  of  the  breath  and 
perspiration,  and  may  be  relieved  by  such  methods  as 
prevent  the  decomposition  of  the  contents  of  the  intes- 
tinal tract. 

The  diamines  are  suspected  from  the  odor  which 
they  give  the  urine,  but  they  may  be  demonstrated 
only  by  exact  chemical  methods  (Simon,  Marriott  and 
Wolf). 


Alkaptonuria  is  an  extremely  rare  condition,  recog- 
nition of  which  depends  on  the  bizarre  symptoms  of 
black  or  inky  urine,  or  at  least  of  urine  that  turns  black 
soon  after  it  is  passed.  The  alkapton  body  (hydro- 
quinone  acetic  acid)  gives  a  precipitate  on  applying 


96  ESSAYS. 

the  copper  sodic  hydrate  sugar  test,  but  does  not  on 
applying  the  fermentation  test.  Thus  some  cases  are 
discovered  among  adults  by  examinations  for  life  in- 
surance. It  is  often  a  congenital  condition,  and  the 
discovery  is  then  made  by  the  inky  stains  on  the  dia- 
pers. The  chromatic  elements  are  deposited  on  the 
ear-drum,  in  the  ear-wax  and  in  the  articular  cartilages. 

The  quantity  of  alkapton  excreted  daily  varies  be- 
tween 45  grains  and  250  grains !  This  is  an  enormous 
amount,  and  yet,  so  far  as  we  know,  the  subjects  are 
perfectly  well. 

These  three  conditions  are  recognized  and  there- 
fore have  been  studied,  because  of  an  unmistakable 
finding  in  each ;  namely,  in  cystinuria  hexagonal  tables 
insoluble  in  alcohol,  ether  or  water;  in  diaminuria  the 
offensive  odor  of  the  urine;  and  in  alkaptonuria  the 
inky  color  of  the  urine  on  standing. 


What  interest  can  these  three  sports  of  excretion 
have  to  the  busy  doctor?  Why  in  the  presence  of  more 
important  problems  be  diverted  to  these  bio-chemical 
curiosities?  The  moral  is  not  far  to  fetch.  Let  us 
take  but  one  of  a  number. 

Here  are  three  conspicuous  abnormalities  of  met- 
abolism without  morbidity.  In  dementia  precox  we 
have  morbidity  of  the  most  serious  and  lasting  kind 
without  any  known  cause.  The  breath  and  urine  are 
loaded  with  acetone  and  other  aromatics,  but  there  is 
no  diabetes  or  starvation.  The  skin  pours  out  abnor- 
mal sebum  and  the  intestines  pour  out  mucus,  but  there 


CYSTINURIA,  DIAMINURIA,  ETC.  97 

is  no  recognized  cause.  The  tendency  to  relapse  is 
conspicuous,  but  no  one  knows  what  initiates  the  ex- 
acerbation. The  blood  shows  a  marked  leucocytosis, 
but  the  vaccines  used  and  agglutination  tests  tried  have 
not  been  interpreted  scientifically.  The  cobra  venom 
produces  a  peculiar  hemolytic  reaction,  but  no  immuni- 
zation has  been  accomplished. 

Nevertheless,  here  is  a  weak  place  in  nature's  abat- 
tis  of  mystery  about  the  aberrant  mind  which  should 
be  charged  with  all  the  force  our  imperfect  biochemi- 
cal science  can  command.  Some  Koch  in  his  mountain 
fastness,  some  Pasteur  in  his  obscure  lecture-room, 
some  Ehrlich  in  his  systematic  laboratory  may  do  the 
trick  that  will  open  the  doors  of  the  madhouses  to 
the  most  unfortunate  of  youths. 


THE  INSTITUTIONS  FOR  THE  INSANE  — 
CUSTODY  OR  CURE? 


IN  our  country  public  service  follows  public  opin- 
ion. How  often,  in  speaking  to  physicians  and  ed- 
ucated laymen,  has  the  fact  that,  of  the  $25,000,- 
000  spent  annually  by  the  forty  sovereign  States 
in  the  care  of  the  insane,  not  $25,000  is  spent  in  the 
study  of  the  causes  of  the  diseases  of  which  insanity 
is  the  overpowering  symptom,  aroused  unstinted  as- 
tonishment? It  is  not  credible  that  so  much  bounty 
is  given  to  the  custody  of  the  lunatic  and  not  one- 
thousandth  to  cure. 

It  is  said  by  many  that  insanity  is  on  the  increase. 
Statistics  from  every  State  in  the  Union  and  from 
every  civilized  European  State  show  an  appalling 
increase  in  the  number  of  incarcerated  insane.  The 
higher  the  civilization  the  greater  the  proportion  of 
the  committed. 

It  is  said  that  among  the  more  barbarous  people, 
such  as  the  Turks,  insanity  is  much  rarer,  and  among 
the  Turks  the  Christian  (alcoholic)  suffer  more  than 
the  Mahommedan  (polygamous). 

It  is  further  affirmed  that  insanities  are  a  constant 
accompaniment  of  European  civilization,  'and  that 
they  are  rarely  observed  among  the  Mongolians  (E. 
Myer).  There  is  only  one  insane  asylum  in  China!1 

1  Mullowney:  The  Need  of  a  Hospital  in  North  China  for 
the  Mentally  Diseased.  China  Medical  Journal,  January,  1911, 

99 


100  ESSAYS. 

In  India  insanity  prevails  to  a  considerable  degree, 
but  the  conditions  make  it  impossible  to  judge  how 
frequent  it  is.  Certainly  it  is  less  prevalent  propor- 
tionately than  in  Europe  and  America. 

When  we  look  the  matter  in  the  face?  we  see  that 
insanity,  like  many  another  human  ailment,  increases 
apparently  with  the  consideration  given  the  condition. 
It  is  likely  that  since  the  time  of  Saul  the  ratio  of  the 
insane  has  increased  with  knowledge,  with  humanity 
and  with  brotherly  love. 

It  is  within  the  memory  of  our  grandfathers  that 
the  insane  were  first  provided  an  asylum  in  this  coun- 
try. How  dreadful  their  condition  before  that  time 
we  cannot  conceive — we  do  not  wish  to  contemplate. 
Through  the  labors  and  the  devotion  of  an  army  of 
humanitarians,  the  States  one  after  another  built  and 
conducted  great  institutions  into  which  the  insane 
were  collected  and  are  kept. 

When  the  insane  were  in  the  poor-houses,  jails  and 
private  pens  with  which  our  ancestors  were  familiar, 
the  custodial  institution  was  the  ideal  of  all  reformers. 
Our  memory  goes  back  to  a  garden  spot  in  northern 
Illinois,  in  1875.  A  wealthy  farmer,  with  large  and 
full  barns  and  a  fine  house,  built  a  pen  in  his  apple 
orchard  where  he  kept  his  insane  son,  and  it  was  our 
misfortune  to  stumble  upon  it.  The  horror  of  the 
place  has  never  left  our  memory,  and  comes  up  after 
more  than  thirty  years  in  our  nightmare  dreams. 

vol.  25,  p.  28:  "Finally,  if  the  signs  of  the  times  do  not  deceive 
us,  this  class  of  diseases  (of  the  mind)  is  on  the  increase 
among  the  Chinese,  and  we  must  make  some  provision  to  take 
care  of  them  properly." 


CUSTODY  OR  CURE?  101 

At  the  present  time  the  campaign  against  the  county 
care  of  the  insane  has  terminated  in  a  surrender  by 
the  county  grafters.  The  end  however,  is  not  actually 
accomplished.  A  few  States  still  promise  to  remove 
the  insane  from  the  county  to  the  care  of  the  State  in 
a  year  or  two.  Even  belated  Wisconsin  is  ashamed 
of  the  county  custody  of  the  incurable  insane,  and  is 
making  strenuous  efforts  to  organize  the  whole  system 
upon  a  rational,  remedial,  educational  basis.  Before 
the  present  legislature  there  is  a  bill  designed  to  con- 
nect the  remedial  institutions  directly  with  the  State 
University,  and  thus  economize  the  facility  of  research 
and  encourage  the  broadest  view  of  the  subject. 

The  standard  of  custody  in  the  several  States  varies 
in  a  most  remarkable  degree.  The  material  construc- 
tion of  the  building,  the  proximity  or  remoteness  from 
the  critical  surveillance  of  large  centers  of  population, 
the  accidents  of  legislation  and  the  personal  equation 
of  practical  politics  and  party  patronage  make  all  the 
difference  between  laudable  efficiency  and  damnable 
spoliation  in  the  conduct  of  asylums. 

Waves  of  reform  have  passed  from  State  to  State, 
from  institution  to  institution,  and  the  average  effi- 
ciency of  the  custodial  asylum  has  risen  from  decade 
to  decade.  Further  improvement  in  this  direction 
seems  almost  impossible,  and  at  the  present  time  the 
conscious  effort  of  all  State  commissions  is  to  secure 
the  passage  of  the  institutions  from  custody  to  cure — 
from  the  protection  of  society  from  the  insane  to  the 
protection  of  the  members  of  society  from  the  catas- 
trophe of  insanity.  The  custodial  institutions  harbor- 


102  ESSAYS. 

ing  tuberculosis,  pellagra  and  slow  starvation  began 
purging  themselves  of  these  institutional  diseases  by 
the  construction  of  special  tuberculosis  hospitals.  The 
second  aroused  them  to  investigating  the  sources  of 
the  malady  and  then  promising,  by  changing  their  ap- 
pellations, to  become  remedial  of  the  conditions  of 
which  all  insanity  is  but  a  symptom. 

This  change  has  come  about  from  a  pressure  from 
without  and  an  impulse  from  within.  There  was  never 
a  time  when  the  medical  waters  were  more  troubled 
than  at  present.  Pure  science  never  advanced  more 
rapidly  than  now.  The  whole  world,  however,  seems 
to  be  possessed  with  a  frenzy  for  the  psychic.  The  old 
religions  are  giving  place  to  deeper  mysticism.  Strange 
cults  with  most  unintelligible  speculative  ontolcgic 
theologies  are  engaged  in  curing  colds  and  in  erecting 
temples  and  cathedrals.  Any  sort  of  pseudo-phi- 
losophy can  secure  a  following  by  the  presentation  of 
the  commonest  incidents  of  mind  in  an  obscure  or 
foreign  persiflage.  Medicine  in  a  measure  follows  the 
fashion.  The  new  psychiatry  explains  all  the  ills  of 
man  from  delirium  tremens  to  appendicitis  on  a  psy- 
chogenetic  basis.  Small  wonder  then  that  the  keepers 
of  the  insane  should  be  taken  with  this  fad.  The 
names  of  all  the  insanities  and  the  names  of  the  jour- 
nals of  lunacy  have  undergone  a  change.  Old  words 
go  with  the  old  philosophy  and  new  words  come  with 
the  new  ontology. 

The  common  people  and  the  medical  profession 
know  little  of  what  is  going  on  behind  the  doors  of 
the  insane  asylums.  The  alienists  are  a  class  by  them- 


CUSTODY  OR  CURE?  103 

selves.  They  are  composed  at  present  of  a  recessive 
group  of  old-fashioned  politicians  with  a  smattering 
of  medicine  and  a  dominant  group  of  new-fashioned 
business  experts  with  a  smattering  of  real  science. 
There  are  a  few  unattached  individuals  among  them 
who  are  real  scientists  with  a  smattering  of  practical 
politics. 

Upon  the  keepers  of  the  insane  have  been  forced  by 
the  trend  of  time  the  change  from  custodial  to  reme- 
dial pretensions.  In  New  York,  a  pathological  insti- 
tute was  added  to  the  system  of  asylums  as  a  central 
training  school  for  the  physicians  and  medical  officers 
of  the  State.  The  school  has  quarters  in  the  city  of 
New  York  with  two  wards  attached  for  study  and 
demonstration.  Psychogenesis  has  been  the  principal 
topic  of  research,  but  a  considerable  amount  of  histo- 
logical  pathology  has  been  undertaken. 

The  hospital  service  in  the  other  institutions  in  New 
York  has  passed  from  the  care  of  the  tuberculous  to 
the  treatment  of  the  acutely  insane,  but  a  reading  of 
the  Twenty-First  Annual  Report  of  the  State  Com- 
mission in  Lunacy  does  not  lead  one  to  think  that  any 
effort  is  being  made  to  seek  the  sources  of  insanity  in 
any  physical  condition,  nor  is  any  accent  placed  upon 
such  therapeutic  measures  as  have  been  empirically 
found  of  some  avail. 

The  former  head  of  the  Pathological  (Psychiatric) 
Institute,  speaking  of  his  guidance  of  its  activities, 
says  (I.e.,  p.  102)  : 

"It  has  taken  much  courage  and  unswerving  de- 
termination to  pass  by  many  of  the  fads  of  the  day, 


104  ESS  A  VS. 

to  appear  unprogressive  in  matters  which  attracted 
the  naive  and  the  clamorers,  to  profess  ignorance  and 
a  passive  attitude  concerning  certain  matters  which 
were  heralded  as  simple  and  final  explanations,  where 
we  were  more  concerned  to  get  a  broader  rather  than 
a  narrower  grip  on  things.  I  cannot  see  that  much 
has  been  missed.  The  result  is  that  we  have  but  few 
outfits  for  work  bought  at  great  expense  merely  to  be 
stored  away  after  the  wave  of  interest  and  disappoint- 
ment had  passed;  and  also  little  of  the  kind  of  no- 
toriety which  looms  bright  in  Sunday  magazines,  ex- 
cites false  hopes,  brings  a  questionable  kind  of  per- 
sonal glory,  and  in  very  rare  instances  a  choice  morsel 
to  those  who  like  to  adorn  their  negative  life  with  an 
'I  told  you  so.' ' 

When  we  take  these  words  in  connection  with  the 
contents  of  the  Psychiatric  Bulletin  and  his  liberal  and 
frank  statement  (Proceedings  of  the  American  Medico- 
Psychological  Association,  sixty- fourth  annual  meeting, 
1908,  p.  130)  of  his  conviction  that  the  insanities  are 
due  to  "peculiar  mental  tangles"  rather  than  to 
"coarsely  appreciable  and  demonstrable  brain  lesions 
or  poisoning,"  not  much  can  be  expected  from  the 
Xew  York  State  Psychiatric  Institute  in  the  way  of 
research  into  the  physical  basis  of  insanity. 

If  we  come  nearer  home  we  find  that  Michigan  has 
a  Psychopathic  Institute  most  fortuitously  situated 
next  door  to  the  hospital  of  the  State  University  at 
Ann  Arbor.  The  institution  occupies  a  very  decent 
building,  commanding  a  beautiful  prospect.  There  are 
three  wards  and  an"  administration  department.  The 
institution  has  no  vital  relation  with  the  university 
although  on  the  campus.  It  has  a  separate  budget  be- 


CUSTODY  OR  CURE?  105 

fore  the  legislature.  It  is  not  vitally  connected  with 
the  asylums  either.  There  is  no  laboratory  work  done 
in  this  institute,  and  patients  receive  no  therapeutic  or 
dietetic  consideration  or  treatment.  They  are  provided 
with  food  if  they  will  eat,  and  expansive  histories  are 
taken  when  they  can  be  elicited.  The  director  is  given 
up  to  the  psychogenetic  origin  of  lunacy.  The  psycho- 
analysis is  carried  out.  The  nurses  are  untrained  and 
of  uncertain  efficiency. 

It  has  not  been  possible  for  us  to  find  the  amounts 
of  money  available  for  the  Institutes  in  New  York  or 
Michigan,  and  an  actuary  has  not  been  consulted.  The 
amounts,  however,  appear  to  have  been  scanty. 

The  proximity  of  the  Michigan  Institute  to  the  Uni- 
versity is  ideal,  but  it  should  be  an  integral  part  of  that 
foundation.  The  departments  of  chemistry,  physiol- 
ogy and  biochemistry  of  the  University  of  Michigan 
are  so  manned  that  they  could  co-operate  with  the  In- 
stitute in  studying  the  problems  of  the  insane.  The 
association  of  all  these  faculties  in  prosecuting  re- 
searches in  metabolism,  chemiotaxis,  hemolysis,  immu- 
nization, as  well  as  the  simpler  problems  of  nutrition 
and  excretion,  would  naturally  and  inevitably  take 
the  activities  of  the  institute  out  of  the  mystical  one- 
iromancy  of  the  transcendental  psychiatrist  (See  ar- 
ticles on  dreams  in  current  psychiatric  periodicals!) 

There  is  no  life  in  the  present  relations  between  the 
Institute  and  the  custodial  asylums  on  the  one  hand, 
and  the  Institute  and  the  University  on  the  other. 
The  literature  shows  no  buds  of  promising  fruit  from 
these  irrational  and  incongruous  alliances. 


106  ESSAYS. 

The  State  of  Illinois  is  one  of  the  most  generous  in 
its  treatment  of  the  insane  and  other  dependents  and 
defectives.  Her  appropriations  are  munificent  and 
the  management  of  her  institutions  are  not  beset  by 
those  harrowing  restrictions  which  are  so  heavy  on 
the  already  almost  breaking  endurance  of  the  friends 
of  the  insane. 

More  than  three  years  ago  (1907)  a  liberal  appro- 
priation ($25,000)  was  secured  for  the  establishment 
of  a  State  laboratory  for  the  study  of  the  condition 
of  the  insane,  with  the  promise  from  its  sponsors  that 
it  would  help  solve  the  problems  of  the  insanities,  to 
the  end  that  some  of  the  insanities  would  be  prevented 
and  some  of  them  cured ;  to  the  end  that  instruction 
could  be  given  in  the  laboratory  to  the  internes  and 
physicians,  who  would  thereby  be  better  able  to  care 
for  the  inmates  and  cure  a  larger  number ;  to  the  end 
that  citizens  would  thus  be  returned  to  useful  posi- 
tions in  the  world,  and  the  State  be  saved  further  cus- 
tody, care  and  expense. 

It  was  a  rational  idea,  and  was  hailed  alike  by  phy- 
sicians, press  and  people  as  a  logical,  promising  and 
worthy  undertaking.  The  result  after  three  years  is 
not  inspiring. 

The  State  Psychopathic  Institute  is  located  in  the 
giounds  of  the  Kankakee  State  Hospital.  It  is  a  cred- 
itable building,  equipped  with  every  instrument  and 
convenience  that  one  could  desire,  and  furnished  with 
a  working  library.  The  space  is  sufficient  and  the 
equipment  adequate  for  a  staff  of  six  or  eight  labora- 
tory men.  The  annual  appropriation,  $4,000  is  not 


CUSTODY  OR  CURE?  107 

enough,  after  paying  the  director's  salary,  to  supply 
the  needs  of  a  single  investigator.  Everything,  how- 
ever, is  in  apple-pie  order.  The  director  of  the  Insti- 
tute is  a  capable  man,  with  a  training  which  recom- 
mends him  to  confidence. 

But  accoutrement,  ammunition,  armament  and  a  gen- 
eral does  not  make  an  army;  no  more  do  equipment 
and  a  director  make  a  laboratory.  The  problems  of 
insanity  require  an  army  of  laboratory  workers  to  un- 
dertake their  solution,  and  the  citizens  of  the  State  of 
Illinois  are  anxious  to  have  the  work  vigorously  pur- 
sued, and  are  willing  to  pay  the  bills.  The  citizens  of 
the  State  and  the  medical  profession  of  the  world  are 
entitled  to  know  how  rationally  and  how  vigorously 
the'  work  is  undertaken,  and  what  answers  nature 
makes  to  the  questions  which  the  ingenuity  of  labora- 
tory men  propose. 

What  is  our  disappointment  to  find  that  our  Psycho- 
pathic Institute  is  without  a  single  laboratory  worker 
except  the  director;  that  the  problems  for  which  the 
laboratory  was  instituted  are  unstated,  and  that  no  ef- 
fort is  made  to  solve  any  of  them;  that  the  director 
himself  does  not  seem  to  us  to  act  as  if  he  believed  in 
the  possibility  of  a  tangible  physical  cause  for  the  in- 
sanities, but  as  if  he  conceived  them  to  be  due  to  "a 
twisted  idea." 

In  the  Institution  Quarterly  (Springfield,  January, 
1911,  page  6)  we  learn  that  the  director  of  the  Psycho- 
pathic Institute  asked  for  an  appropriation  of  $16,000 
a  year  for  the  coming  two  years — $12,500  for  salaries 
and  $3,500  for  books,  instruments,  chemicals  and  mis- 


108  ESSAYS. 

cellaneous  expenses.  In  the  most  naive  manner  the  fis- 
cal supervisor,  with  the  cocksure  self-reliance  of  a  bus- 
iness man,  allows  only  $11,800,  as  follows:  "Salary  of 
director  $3,500,  clinical  assistant  $1,800,  clinical  path- 
ologist $1,800,  two  stenographers  $1,200,  chemist 
$1,200  and  janitor  $300.  For  books,  instruments,  chem- 
icals and  other  expenses,  $2,000  per  annum  will  be 
ample." 

It  will  be  noticed  that  only  one  person  is  expected 
to  work  in  this  laboratory ;  the  rest  are  clinical,  namely, 
the  clinical  assistant,  the  clinical  pathologist  and  two 
stenographers.  Possibly  the  janitor  and  the  chemist 
together  can  do  some  laboratory  work. 

But  let  us  see  how  the  Board  of  Administration  in- 
terprets the  fundamental  law  establishing  not  only  the 
Psychopathic  Institute  but  the  Board  itself  (Code  of 
Charities,  approved  June  15,  1909),  in  the  preamble  of 
which  are  these  pregnant  words,  outlining  the  objects 
of  the  act:  "To  promote  the  study  of  the  causes  of  de- 
pendency ctoid  delinquency,  and  mental,  moral  and  phys- 
ical defects,  itrith  a  view  to  cure  and  ultimate  preven- 
tion," and  further  that  this  act  "sh-all  be  liberally  con- 
strued to  these  ends."  In  general  orders  No.  6  of  the 
Hoard  of  Administration,  the  work  of  the  Psycho- 
pathic Institute  is  so  fully  outlined  that  it  leaves  no 
doubt  in  the  mind  of  any  considerate  reader  that  so 
far  as  a  study  of  the  physical  causes  of  the  insanities 
gees  there  is  "nothing  doing"  at  Kankakee.  One  par- 
agraph out  of  these  pages  is  enough  to  quote  here: 
"Its  chief  function  shall  be  the  teaching  of  psychiatry 
:md  of  the  most  advanced  conceptions  in  neurology,  in 


CUSTODY  OR  CURE?  109 

so  far  as  neurology  relates  to  psychiatry,  and  such  re- 
search work  as  may  aid  in  the  establishment  of  a  more 
modern  and  effective  system  of  caring  for  the  insane, 
feeble-minded  and  epileptic." 

In  New  York  the  Pathological  Institute  has  become 
a  "Psychiatric  Institute,"  in  Michigan  the  Psycho- 
pathic Hospital  has  never  been  in  any  sense  a  hospital 
or  pathologic  institute  and  has  absolutely  no  connec- 
tion with  the  university  and  its  laboratories,  in  the 
grounds  of  which  itis  located ;  and  in  Illinois  the 
Psychopathic  Institute  is  loaded  down  with  routine 
and  educational  work  of  the  most  primitive  descrip- 
tion, and  is  wholly  given  up  to  psycho-analysis  to  the 
complete  neglect  of  original  research  of  a  chemical, 
hematological  and  serological  character,  or  to  meta- 
bolic studies  of  such  a  nature  as  every  metropolitan 
hospital  now  maintains  for  patients  whose  conditions 
are  already  solved  problems. 

So  it  seems  that  the  omnipotent  if  not  omniscient 
Board  of  Administration  is  keeping  up  a  paper 'psy- 
chopathic institute  on  $4,000  a  year,  and  proposes  to 
keep  it  up  on  an  appropriation  of  $11,000  per  annum, 
in  spite  of  their  salary  and  oath  of  office,  in  which 
oath  they  swore  to  construe  the  "Code  of  Charities" 
liberally. 

If  the  State  of  Illinois  had  15,000  of  its  average 
citizens,  old  and  young,  rich  and  poor,  incarcerated  in 
however  gentle  a  durance  by  an  inexorable  enemy, 
would  this  great  State  send  out  an  army  of  deliverance 
consisting  of  a  single  general  and  equipment  for  less 
than  ten  men — but  no  men  at  all?  Would  the  State 


no  ESSAYS. 

send  out  a  general  who  they  had  reason  to  believe 
doubted  that  these  15,000  citizens  were  forcibly  re- 
strained and  kept  in  involuntary  confinement — a  gen- 
eral who,  however  expert  in  the  arts  of  war,  had  no 
enthusiasm  for  the  cause  at  issue? 

Here  we  have  the  director  for  three  years  of  a  psy- 
chopathic institute,  equipped  with  all  the  instruments 
to  combat  ignorance,  with  rabbits,  guinea-pigs  and 
monkeys  in  abundance,  and  not  a  worker  in  the  lab- 
oratory ;  more  than  that,  without  any  potent  conviction 
of  the  physical  cause  of  mental  aberration.  The  rab- 
bits and  guinea-pigs  multiply,  new  cases  of  insanity 
come  into  the  hospital  every  day,  the  janitors  keep  the 
equipment  clean  and  presentable,  and  the  director  of 
the  State  Psychopathic  Institute  pursues  the  study  of 
insanity  by  inquisitorial  methods  that  need  no  instru- 
ments except  the  pencil  of  the  stenographer  and  no 
equipment  except  his  stop  watch  and  the  table  and 
chairs  of  a  parlor. 

The  director  of  the  Psychopathic  Laboratory,  more- 
over, has  had  the  care  and  duties  of  a  ward,  and  also 
the  wholly  extraneous  labor  of  a  medical  schoolmas- 
ter. These  duties  have  been  undertaken  in  addition  to 
time-consuming  duties  of  the  ancillary  commission  for 
the  protection  of  the  corn  crop,  namely,  the  Pellagra 
Commission. 

These  things  are  not  written  as  a  complaint,  but  as 
a  petition.  Our  contention  is  that  the  insanities  are 
etiologically  physical  ailments,  and  that  their  under- 
standing is  to  be  attained  by  physical  laboratory  meth- 
ods based  on  rational  theories.  With  us,  apparently, 


CUSTODY  OR  CURE?  Ill 

was  the  legislature  of  the  State,  that  enacted  the  Code 
of  Charities,  and  the  promoters  of  this  first  State  lab- 
oratory for  the  study  of  the  insanities.  If  it  had  been 
the  Freud  theory  and  the  Jung  inquisition  that  the  leg- 
islature contemplated  in  the  acts  of  1907  and  1909, 
there  would  have  been  no  need  of  apparatus.  The 
treatment  rooms  of  any  Christian  Science  temple  are 
ample  for  this  method.  If  workers  in  the  laboratory 
are  not  furnished  by  the  Board  of  Administration,  the 
director  is  helpless.  He  is  in  the  position  of  a  gen- 
eral without  an  army. 

There  is  a  disease  among  cattle  which  we  may  hear 
about  if  something  is  not  soon  done  to  stop  its  spread 
in  the  Mississippi  Valley.  It  is  known  among  Euro- 
pean veterinarians  as  "epidemic  contagious  abortion." 
Bacteriologists  have  recognized  and  identified  it  in 
various  parts  of  Illinois.  Now  let  us  venture  a  pro- 
phecy !  When  the  stockmen  and  farmers  are  unable 
to  conceal  the  presence  of  this  disease  any  longer,  they 
will  appeal  to  the  legislature  and  get  without  opposi- 
tion an  appropriation  of  $50,000  or  more  a  year  for 
the  "Institute  of  Epidemic  Contagious  Abortion  of 
Cattle/'  The  Dairymen's  Association  (Act  of  June 
11,  1909)  will  not  fail  to  vigorously  look  for  the 
means  of  preventing  this  disease  and  they  will  not 
resort  to  any  stripped  poplar  rods  or  other  sacerdotal 
device  (Genesis  30:  32-43)  or  fail  to  liberally  interpret 
the  acts  of  the  legislature. 

In  Chicago,  and  at  Urbana  and  Evanston,  as  well  as 
elsewhere  in  the  State,  there  is  a  round  score  of  young 
men  trained  in  many  of  the  rational  methods  of  the 


112  ESSAYS. 

laboratory  and  having  the  ingenuity  and  the  scientific 
prescience  which  can  ask  answerable  questions  of 
nature,  and  get  indubitable  and  intelligible  replies. 
These  men  are  ready  to  serve  an  enthusiastic  and  un- 
swerving director  in  the  pursuit  of  so  worthy  an  ob- 
ject as  that  for  which  this  laboratory  was  established. 
The  salary  which  the  Sta.te  pays  internes  and  physi- 
cians is  adequate,  the  motive  obvious  and  laudable  and 
the  chances  of  progress  are  hope-inspiring. 

While  considering  the  sort  of  workers  likely  to 
make  good  in  a  psychopathic  laboratory,  the  last 
number  of  the  Edinburgh  Reviezv  (January,  1911) 
opened  to  an  article  on  heredity  beginning  with  these 
oracular  words:  "It  is  an  interesting  question  as  to 
how  far  the  solution  of  a  vexed  problem  is  facilitated 
by  the  preliminary  study  of  previous  attempts  to  soVe 
it.  Most  people  if  asked  off-hand  would  regard  it  as 
an  axiom  that  the  history  of  opinion  on  the  subject 
they  are  studying  must  be  of  some  value  in  advancing 
that  study.  Yet  in  many  problems  of  science  *  *  *  * 
we  are  inclined  to  believe  that  correct  solutions  are 
more  likely  to  be  achieved  by  a  mind  coming  fresh 
from  the  prevailing  atmosphere  of  modern  times  than 
by  one  steeped  in  the  heterogeneous  mixture  of  truth 
and  absurdity  which  emanated  from  a  less  scientific 
era."  These  words  express  our  own  notion  of  the 
equipment  of  the  laboratory  men  who  must  be  looked 
to  by  us  to  dispel  our  ignorance  of  the  origin  of  the 
insanities.  The  State  has  furnished  the  equipment, 
the  universities  of  the  State  have  educated  the  young 
men,  the  power  is  in  the  board  of  administration,  the 


CUSTODY  OR  CURE?  113 

medical  profession  of  the  State  expects  results,  the 
citizens  of  the  State  demand  action  and  efficiency, 
and  all  this  time  in  a  durance  worse  than  that  of  the 
victims  of  the  Cherry  coal  mine,  15,000  helpless 
wait. 

Of  course  we  cannot  expect  each  of  the  forty  sov- 
ereign States  to  have  an  Ehrlich  or  a  Flexner  as  a 
director,  but  certainly  there  are  latent  Noveys  in  every 
one  of  the  States  and  potential  Welches  in  every  uni- 
versity. The  problems  are  so  fundamental  and  our 
ignorance  is  so  dense  relative  to  all  the  sources  of 
insanity  that  the  greatest  liberty  must  be  given  the  in- 
vestigators to  pursue  what  might  be  considered  a  priori 
unreasonable  tangents.  The  best  director  is  the  one 
with  the  scientific  imagination,  the  immovable  purpose 
and  the  perception  which  sees  all  the  possibilities  in 
the  clamorous,  the  enthusiast,  the  sturdy  and  the  naive 
—he  is  the  thorough  and  patient  investigator  whose 
motive  and  method  inspires  his  associates  to  indefatig- 
able labor. 

The  service  of  the  State  institutions  of  charity  has 
a  bad  reputation  among  medical  and  scientific  men. 
The  State  universities  are  exempt  from  such  imputa- 
tions in  varying  degrees.  The  University  of  Michigan 
has  long  been  honored  by  staunch  members  of  its 
faculty  and  by  the  unsullied  devotions  of  a  long  line 
of  trustees  who  have  given  their  best  years  to  its  un- 
divided interests. 

The  radical  departure  of  Illinois  in  the  Code  of 
Charities  of  1909,  placing  the  management  of  its  insti- 
tutions under  a  Board  of  Administration,  must  be 


114  ESSAYS. 

looked  upon  by  all  the  friends  of  the  insane  and  by 
political  scientists  with  anxious  expectation.  The  Act 
distinctly  states  in  its  preamble  that  it  shall  be  inter- 
preted liberally  looking  toward  cure  and  prevention. 
The  Board  of  Administration  may  take  the  narrow 
businesslike  statutory  view  of  their  duties  or  they  may 
take  the  broad  and  liberal  view  that  has  always  guided 
the  trustees  of  the  University  of  Michigan.  They  may 
wait  for  statutory  mandates  for  all  their  activities  or 
they  may  take  the  Code  of  Charities  at  its  word  and 
pursue  the  study  of  the  causes,  they  may  seek  a  method 
of  prevention  and  cure  of  the  maladies  of  their  wards 
with  all  the  resources  which  a  generous  and  wealthy 
State  has  heretofore  and  will  hereafter  appropriate 
at  the  request  of  an  efficient,  an  honest  and  a  vigorous 
administration.  The  danger  of  a  fitful  and  rapidly 
changing  administration  has  past.  Whatever  befalls 
can  now  be  placed  at  the  door  of  the  Board.  If  they 
save  at  the  spigot  while  they  spill  at  the  bung,  it  w;ll 
be  easy  to  show  who  is  responsible.  In  the  manage- 
ment of  the  State  charities  as  nowhere  else,  an  ounce 
of  prevention  is  worth  a  pound  of  cure.  It  is  in  re- 
search and  education  and  not  in  economy  in  pur- 
chasing or  in  efficiency  of  custody  that  we  must  expect 
the  most  praiseworthy  action  of  the  Board. 

It  has  always  been  our  contention  that  the  Psycho- 
logic Institute  should  report  to  and  be  an  integral  part 
of  the  University,  both  in  Michigan  and  Illinois.  The 
advantages  of  a  close  association  between  the  chemical, 
biochemical,  bacteriological,  botanical,  dairy,  entomo- 
logical, zoological,  veterinary,  engineering  and  legal 


CUSTODY  OR   CURE?  115 

faculties  cannot  be  overestimated  when  approaching 
the  dark  problems  of  insanity  and  delinquency. 

We  are  certainly  warranted  in  the  statement  that 
there  is  no  likelihood  of  any  vigorous  systematic  in- 
vestigation into  the  physical  causes  of  insanity  at  the 
Institutes  of  New  York,  Michigan  or  Illinois.  Some- 
where, sometime,  this  work  will  be  carried  to  com- 
pletion. 

With  the  establishment  of  similar  institutes  in  the 
various  States  we  may  hope  for  happy  conditions  and 
a  favorable  outcome  in  some  of  them.  In  a  problem 
of  such  obscurity  too  many  independent  methods  of 
research  can  hardly  be  possible.  Every  Institute  would 
have  a  personality  and  individuality  of  its  own. 

It  was  in  South  Carolina  that  pellagra  was  first 
recognized,  though  there  is  every  reason  to  believe  it 
had  existed  elsewhere,  even  in  Illinois,  for  thirty  years. 
It  is  possible  that  some  local  condition  or  combination 
of  conditions  will  furnish  the  key  that  will  unlock  the 
door  which  has  kept  dark  the  etiology  of  the  diseases 
of  which  the  insanities  are  symptomatic. 

The  smuggest  parsimony  would  dictate  that  for 
every  hundred  dollars  appropriated  by  the  State  for 
custody  of  the  insane  one  dollar  at  least  be  expended 
directly  in  research  into  the  causes  of  insanity. 


BERIBERI  AND  DEMENTIA  PRECOX  OR 
ADOLESCENT  INSANITY. 


HOLDING,  as  we  do,  that  adolescent  insanity  is  a  phys- 
ical ailment,  of  which  either  exceptionally  or  uniformly 
mental  deterioration  or  dementia  is  a  compelling  symp- 
tom, we  naturally  seek  analogies  in  other  diseases.  In 
preceding  pages  certain  conditions  have  been  consid- 
ered which  seem  to  us  to  strengthen  our  position.  We 
naturally  seek  further  analogies  in  unexplained  dis- 
eases that  affect  the  nervous  system,  and  have  selected 
beriberi  from  a  long  list  ranging  all  the  way  from  gout 
and  pernicious  anemia  to  the  obscure  disease  known 
as  milk-sickness. 

There  is  a  remarkable  similarity  in  the  attitude 
which  the  majority  of  clinicians  held  toward  tubercu- 
losis in  the  sixties  and  seventies  of  the  past  century 
and  the  attitude  of  the  alienists  of  to-day  toward  de- 
mentia precox,  or  adolescent  insanity.  One  can  parallel 
the  arguments  of  these  widely  separated  classes  for  an 
intangible,  inscrutable,  inexorable  source  of  each  dis- 
ease. The  clinical  deductions  and  the  conflicting  ex- 
perimental investigations  of  tuberculosis  as  brought  to- 
gether by  Max  Schiller  (1868)  had  little  influence  on 
entrenched  opinion  until  Robert  Koch's  irrefutable 
biologic  investigation  swept  away  the  last  vestige  of 
medieval  mysticism  relative  to  tuberculosis.  In  regard 
to  the  origin  of  insanity,  or  of  the  insanities,  the  alien- 
ists are  desperately  fixed  upon  psychogenesis. 

At  a  recent  meeting  of  the  Chicago  Neurological 
117 


118  ASSAYS. 

Society,  at  which  a  clear-cut  chemical  investigation  of 
the  brain  in  dementia  precox  was  presented,  the  amen 
corner  was  politely  attentive  but  unanimously,  though 
diplomatically,  pronounced  for  the  psychogenetic  origin 
of  dementia  precox,  and  naturally  for  the  psycho- 
genetic  origin  of  the  chemical  pathology  demonstrated 
by  the  investigator. 

The  literature  of  yellow  fever  is  also  analogous  to 
the  present  literature  of  dementia  precox  in  the  prom- 
inence given  the  hereditary,  the  psychic  and  the  theoric. 

The  literature  of  the  plague  furnishes  innumerable 
parallels  to  the  current  literature  of  psychiatry. 

The  literature  of  Asiatic  cholera  as  late  as  1866,  and 
in  sane  America,  put  forth  the  psychic  as  a  powerful 
factor  in  the  onset  of  the  disease. 

Beriberi  or,  as  the  Japanese  call  it,  kakke  is  a  disease 
of  unknown  origin  and  of  world-wide  distribution 
throughout  the  temperate  zones  and  the  tropics.  It 
seems  to  have  its  geographic  centre  of  intensity  about 
the  China  Sea,  but  it  is  confined  by  no  continent,  lim- 
ited by  no  ethnology  and  excluded  by  no  civilization. 
While  it  seems  to  be  endemic  or  to  arise  spontaneously 
in  the  prisons,  asylums  and  capitalistic  labor  pens  of 
the  world,  it  attacks  the  best  fed  armies  and  navies,  and 
ravages  the  wealthiest  and  most  cultured  classes  in 
Japan.  It  is  a  disease  which  has  been  known  from  the 
earliest  antiquity,  but  has  received  until  recently  only 
scant  attention  from  the  medical  profession  of  Europe 
and  America.  The  Japanese  tell  us  that  kakke  was 
well  described  by  the  Chinese  two  hundred  years  be- 
fore Christ,  and  Strabo  recounts  an  epidemic  in  the 


BERIBERI  AND  DEMENTIA   PRECOX.          119 

Roman  army  invading  Arabia  24  B.  C.  The  Japanese 
navy  had  for  years  been  paralyzed  by  the  disease  until 
Surgeon  Takaki  introduced  a  strictly  scientific  daily 
ration.  From  the  Japanese  army  during  the  war  with 
Russia  more  than  50,000  were  sent  home  with  kakke 
during  the  first  year,  and  many  died  of  the  acute  disease 
at  the  front.  Commencing  with  the  second  month  of 
activities,  March,  1905,  when  the  first  ten  were  sent 
back  to  Japan  with  the  chronic  disease,  the  following 
were  returned  each  month  during  the  calender  year: 
65;  108;  253;  1,602;  7,960;  13,505;  10,811;  9,344; 
and  6,628. 

The  disease  is  endemic  in  the  Philippines  and  in  the 
Dutch,  English  and  French  possessions  in  the  Orient. 
It  is  endemic  in  Africa  from  end  to  end  where  its 
afebrile  course  is  in  marked  contrast  to  the  fulminating 
diseases  of  that  disease-ridden  continent. 

Beriberi  has  often  been  noticed  in  the  \Yestern  hemi- 
sphere— in  South  America,  in  Panama,  in  the  Carib- 
bean Islands  and  Mexico  and  among  the  fishermen  on 
the  banks  of  Newfoundland.  Putnam,  in  1890,  re- 
ported cases  in  New  England ;  seventy-one  cases  were 
observed  in  the  insane  at  Tuscaloosa,  Ala.,  in  1896, 
and  a  large  number  in  the  Arkansas  Insane  Hospital 
at  Little  Rock  the  same  year.  It  1/as  been  endemic  in 
Louisiana  for  twenty  years  at  least,  and  was  reported 
in  1910  by  Jervey  and  Butler  in  an  epidemic  among  the 
convicts  at  Ten-Mile  Hill,  Charleston  County,  S.  C. 
In  two  weeks  in  the  month  of  March  150  out  of  300 
convicts  came  down  with  the  disease,  and  the  physician 
of  the  old  prison  from  which  they  came  recalled  many 


120  ESSAYS. 

previous  epidemics  of  the  same  condition  which  had 
passed  unnamed  during  the  preceding  twenty  years. 
In  the  Texas  Lunatic  Asylum  at  Austin  there  was  an 
epidemic  in  1907  with  200  chronic  cases  and  twenty 
deaths  'among  the  acute  cases.  There  is  no  doubt  that 
many  other  sporadic  cases  throughout  the  United 
States  are  overlooked  because  the  disease  is  not  studied 
by  our  profession. 

Beriberi  is  an  acute  or  chronic  infections  toxemia, 
characterised  clinically  by  disturbances  of  circulation, 
of  motion  and  of  sensation,  and  associated  anatomically 
i(.'iih  hypertrophy  and  degeneration  of  the  heart,  of  the 
peripheral  nerves  and  of  the  voluntary  muscles. 
(Wright).  It  has  been  called  endemic  polyneuritis 
(Baelz)  and  endemic  multiple  neuritis  (Scheube). 

When  the  United  States  soldiers  in  the  Philippines 
came  down  with  beriberi  the  Bureau  of  Science  began 
the  study  of  the  disease.  Herzog  produced  his  two 
careful  studies  of  the  disease  which  offered  a  clear 
picture  of  the  above  situation  (Philippine  Journal  of 
Science,  Vol.  I,  No.  7,  September,  1906,  pp.  709-764). 
He  investigated  the  claim  of  the  Okato-Kokubo  coccus 
in  the  hospitals  of  Japan  and  took  cultures  back  to  the 
Philippines  for  further  study.  He  set  aside  this  claim 
on  every  ground  and  began  the  study  anew.  His  ma- 
terial was  carefully  observed  and  cannot  fail  to  be  of 
inestimable  value  to  subsequent  systematic  students. 

During  the  succeeding  six  years  much  has  been 
added  to  the  history  of  kakka,  of  which  a  brief  outline 
may  be  interesting. 

Inagaki,  Horiuchi,  Hakase  and  Nemori  have  been 


BERIBERI  .-LVD  DEMENTIA   PRECOX.          121 

led  from  a  study  of  a  toxic  colloid  in  the  milk  of 
mothers  suffering  of  kakke  and  the  milk  of  other 
mothers  who  came  down  with  kakke  as  soon  as  the 
milk  dried  up,  to  a  study  of  the  fermentation  of  rice 
and  kaka  diastase,  in  a  search  for  the  origin  of  the 
disease.  They  are  quite  agreed  that  the  disease  is  due 
to  a  yeast  which  is  found  both  in  boiled  rice  and  in 
kaka  diastase.  The  reading  of  these  articles  is  very 
convincing  of  the  ability,  scientific  integrity  and  abso- 
lute frankness  of  the  invetsigators,  but  it  furnishes  no 
adequate  clinical  support. 

The  clinical  students  of  kakke  have  long  known  that 
sucklings  of  mothers  who  have  chronic  beriberi  do  not 
always,  though  they  do  frequently,  suffer  of  the  dis- 
ease. Now  another  clinical  observation  is  relevant, 
that  many  nursing  mothers  whose  previous  history  only 
remotely  suggests  beriberi  come  down  with  a  severe 
form  of  the  disease  as  soon  as  their  breasts  dry  up. 
Again,  many  perfectly  healthy  mothers  lose  infants 
from  an  uncertain  disease  and  when  the  milk  dries  up 
the  mothers  come  down  with  beriberi  and  it  becomes 
evident  that  the  child  died  of  the  acute  disease. 

The  Japanese  authors  referred  to  began  in  the  light 
of  these  clinical  observations  a  careful  study  of  moth- 
ers' milk.  In  the  milk  of  beriberi  mothers  they  found 
a  toxic  substance  which  paralyzed  the  frog's  heart  in  a 
characteristic  manner.  This  substance  was  also  found 
in  the  feces  of  kakke  patients  and  in  rice  fermented 
with  a  specific  yeast.  It  is  their  conclusion  that  rice 
fermentation  with  this  yeast  goes  on  in  the  intestinal 
tract  and  generates  the  beriberi  toxin  which  is  the  true 
cause  of  the  disease. 


122  ESSAYS. 

While  this  work  was  going  on  in  Japan,  Frasier  and 
Stanton  made  an  experiment  with  chickens,  which 
seems  to  indicate  that  polished  rice  is  the  basis  of  the 
disease.  They  fed  groups  of  twelve  chickens  on  pol- 
ished rice  and  other  groups  of  twelve  chickens  on  un- 
polished rice.  At  the  end  of  sixty  days  kakke  devel- 
oped among  the  former  groups,  the  latter  remaining 
well.  They  then  took  some  of  these  groups  for  a  re- 
versal of  the  food.  Again,  at  the  end  of  sixty  days, 
the  chickens  that  had  been  well  during  the  first  period 
became  sick  and  the  sick  chickens  got  well.  They  had 
an  opportunity  to  try  out  the  same  food  experiments 
on  several  gangs  of  healthy  railway  laborers  in  Siam. 
They  fed,  besides  other  food,  polished  rice  to  one  gang 
and  unpolished  rice  to  another  gang.  In  two  months 
those  fed  on  polished  rice  had  beriberi  as  usual,  those 
fed  on  unpolished  rice  were  all  free  of  the  disease. 
Now  the  food  conditions  were  reversed,  and  in  due 
time  the  sick  became  well  and  the  well  sick.  Fink 
tried  the  rice,  polished  and  unpolished,  on  parrots  with 
identical  results  and  reversing  the  food  the  sick  got 
well  and  the  well  sick.  Aron  made  a  study  of  the  con- 
stituents of  the  polished  and  unpolished  rice  and  con- 
cluded that  the  phosphorus-bearing  husk  might  be 
necessary  to  health.  Experiments  in  using  polished 
rice  and  adding  a  proportionate  quantity  of  husks  seem 
to  favor  Aron's  contention. 

In  the  rules  of  the  Administration,  civil,  military 
and  naval,  the  use  of  polished  rice  is  prohibited  in  the 
Philippines.  (Reiser,  Journal  A.  M.  A.,  Vol.  57,  April 
29,  1911,  p.  1238).  The  results  have  warranted  the 


* 

BERIBERI  AND  DEMENTIA  PRECOX.          123 

rule.  There  are  many  places,  however,  where  no  rice 
is  used  and  yet  beriberi  is  endemic. 

Tanaka  reviews  the  whole  subject  and  holds  to  the 
theory  that  kakke  is  due  to  a  micro-organism  growing 
in  the  intestine  on  a  rice  diet.  This  would'  not  be  in- 
consistent with  the  yeast  intoxication  theory. 

Heighet  (Bankok),  in  the  twelfth  annual  report  of 
the  Siam  health  office  (Journal  Tropical  Medicine,  Vol. 
13,  p.  323),  reports  a  most  terrible  outbreak  of  kakke. 
Out  of  400  only  227  remained  at  the  end  of  two  weeks 
when  parboiled  rice  was  used  with  remarkable  benefit. 

There  are  many  respects  in  which  beriberi  resembles 
dementia  precox :  ( 1 )  It  attacks  the  young,  less  often 
infants  and  old  adults.  (2)  It  is  manifest  in  an  acute 
and  rapidly  fatal  and  a  chronic  and  a  recurrent  form. 

(3)  It  is  generally,  though  not  always,  an  afebrile  con- 
dition and  even  in  the  most  tropical  regions  kills  rap- 
idly   with    no    disturbance   of    temperature    (Plehn). 

(4)  It  generally  begins  with  malaise  and  abdominal 
distress.     This  is  rarely  pain,  but  a  most  distressing 
discomfort.     (5)  There  is  an  incubation  or  prodromal 
period  of  ten  to  fifteen  days  (Wright).     (6)  There  is 
early    disturbances    of    sensation    of    all    five    senses. 
(7)  The  heart's  action  is  accelerated  and  the  blood- 
pressure  falls  below  normal.    This  continues  over  con- 
siderable periods  in  both  diseases.     (8)   In  nearly  all 
cases  of  both  diseases  there  is  dilation  of  the  heart, 
shown  by  the  increased  cardiac  dullness,  displacement 
of  the  apex  to  the  left,  and  in  the  worst  cases  distinct 
murmurs.     (9)  The  urine  in  both  diseases  is  dimin- 
ished at  first  and  contains  indican.    The  urine  increases 


* 
124  ESSAYS. 

\vith  improvement  or  recovery.  Albumin  is  rarely 
present  in  either  disease  and  when  it  is  concomitant 
accidents  are  present  to  account  for  it.  (10)  In  both 
diseases  there  is  at  times  an  edematous  condition  of 
the  whole  body  or  of  certain  circumscribed  regions. 
On  the  face  and  extremities  this  edema  is  most  con- 
spicuous. (11)  There  is  in  both  diseases  a  lilac  tinted 
cyanosis  which  shows  itself  in  localities  such  as  the 
fingers  and  toes,  certain  areas  on  the  cheeks  and  lips. 

(12)  Improvement  follows  when  hygienic  changes  are 
made  early  in  the  disease.     After  it  has  continued  a 
longer  time,  relative  recovery  alone  can  be  expected. 

(13)  Both  diseases  encourage  the  onset  of  tuberculosis, 
dysentery  and  in  some  localities  malaria.     (14)  The 
result  in  both  diseases  is  a  certain  inco-ordination  of 
motion,  which  is  termed  by  the  alienists  mannerism. 
(15)  The  death  rate  in  the  chronic  disease,  both  of 
beriberi  and  dementia  precox,  is  small,  2  to  5  per  cent. 

By  these  analogies  we  would  suggest  that  the  proper 
attitude  toward  beriberi,  kala-azar,  pellagra  and  the 
milk-sickness  of  our  prairies  is  the  proper  attitude  to- 
ward adolescent  insanity.  Dementia  precox  is  no 
dream,  it  is  no  inscrutable  dispensation  of  providence, 
it  is  no  engulfing  habit.  It  is  a  toxemia  of  tangible, 
material  origin,  which  a  suitable  application  of  the  in- 
exhaustible cunning  of  the  human  mind  will  bring  to 
light  and  subjugation. 


PELLAGRA  AND  ADOLESCENT  INSANITY. 


No  DISEASE  has  so  aroused  the  imagination  and  fear 
of  the  country  people  of  the  Mississippi  Valley,  what- 
ever indifference  the  medical  profession  may  manifest, 
as  pellagra  has  recently  done;  .and  no  yellow  journal 
tale  of  institutional  atrocities  has  caused  such  anguish 
and  alarm  to  the  friends  of  the  insane  as  the  appear- 
ance of  pellagra  in  the  generously  supported  asylums 
of  custody  of  the  Central  United  States. 

This  disease  is  relatively  new  to  medicine  or,  if  not 
new,  it  was  long  confounded  with  the  many  other  allied 
conditions  of  which  men  have  suffered  so  patiently. 
Unlike  beriberi,  it  is  a  disease  of  the  country  rather 
than  of  the  city.  It  is  a  seasonable  disease  attaining 
its  height  in  midsummer  or  early  autumn.  Its  geo- 
graphic center  of  intensity  is  not  about  any  sea  or 
ocean,  but  in  the  great  river  basins,  especially  in  the 
Valley  of  the  Po  and  of  the  Nile.  It  is  a  disease  of 
many  and  bizarre  symptoms  and  no  brief  epitome  of 
its  manifold  manifestations. can  here  be  given,  but  they 
are  well  known  and  are  indubitably  vocative  of  a  toxi- 
infectious  process. 

The  older  physicians  of  the  country  who  now,  for 
the  first  time,  see  named  cases  of  pellagra  collected  to- 
gether in  the  asylums  and  poorhouses,  recall  from  the 
memory  of  the  early  years  of  their  practice  similar  cases 
which  they  were  never  able  to  place  in  any  nosologic 
category.  For  example,  my  butler,  who  is  an  intelli- 

125 


126  ESSAYS. 

gent  colored  man  from  Georgetown,  Mo.,  refused  when 
he  first  came  to  me  in  the  eighties,  to  eat  any  corn 
bread  because,  he  said,  it  brought  on  a  corn  scrofula. 
He  described  to  me  at  length  the  condition  of  a  neigh- 
bor's boy,  Tom  Paulin,  the  son  of  a  widow,  Sarah 
Paulin,  who  had  this  terrible  disease.  It  came  on 
every  summer  from  1882  to  1887,  and  made  a  raw 
collar  about  his  neck  and  a  sort  of  dickey  on  his  chest 
and  a  glove-like  bealing  on  his  forearms  and  a  stock- 
ing-like blistering  on  his  legs.  An  old  doctor 
named  William  Brocksmith,  who  I  find  practiced 
in  Sedalia,  Mo.,  in  1886,  and  was  put  down  in  Folk's 
Directory  as  from  Berlin,  Prussia,  '65,  told  the  Paulin 
folks  that  this  disease  was  due  to  eating  Indian  corn. 
My  attempts  to  find  Tom  Paulin  have  not  been  suc- 
cessful, but  considerable  information  which  medical 
men  of  Sedalia  have  furnished,  substantiates  the  pre- 
sumption that  in  1882  Tom  Paulin  had  pellagra  and 
that  Dr.  Brocksmith  recognized  it. 

The  recent  discovery  of  pellagra  in  the  United  States 
is  a  symptom  of  one  of  two  things.  Either  profes- 
sional accuracy  and  integrity  have  greatly  increased,  or 
an  epidemic  appearance  of  a  previously  sporadic  dis- 
ease has  occurred.  We  know  now  that  pellagra  is  not 
limited  by  any  state  or  by  the  economic  conditions  of 
life.  Like  beriberi,  pellagra  has  been  looked  upon  as 
a  dietetic  disease.  It  probably  stands  in  no  closer  re- 
lation to  diet  than  kakke,  milk  sickness,  infantilism  (of 
Herter)  and  diabetes. 

Pellagra,  like  beriberi,  has  a  marked  effect  upon  the 
nervous  system.  Beriberi  shows  its  effect  upon  the 


PELLAGRA   AND  ADOLESCENT  INSANITY.    127 

peripheral  nerves  and  the  motor  nerves  of  respiration 
and  circulation,  while  pellagra  manifests  itself  in  cere- 
bration. In  Italy  about  10  per  cent,  of  the  pellagrins 
are  insane,  but  in  the  United  States  the  proportion  of 
insane  pellagrins  is  certainly  much  higher. 

Assuming  that  pellagra  and  dementia  precox  are 
toxi-infectious  diseases,  we  have  found  many  analogies 
between  them.  (1)  Both  diseases  attack  the  young  in 
about  equal  proportions,  regardless  of  sex.  (2)  There 
is  an  acute  fatal  and  a  chronic  relapsing  form  of  both 
diseases.  (3)  While  both  diseases  are  multifarious  in 
their  manifestations,  they  are  likely  to  assume  at  any 
time  unmistakable  pathognomonic  features.  (4)  Both 
diseases  are  intermittent  and  seasonable,  but  pellagra 
markedly  seasonable.  (5)  The  symptomatologies  of  the 
two  diseases  have  been  so  differently  interpreted  that  no 
two  authors  agree  in  the  types  or  systems  in  which 
they  elect  to  classify  cases.  (6)  Both  diseases  are 
prone  to  have  a  long  prodromal  period,  though  either 
of  them  may  seem  to  come  on  suddenly.  (7)  They  are 
alike  in  the  early  gastro-intestinal  symptoms,  the  ma- 
laise, the  disturbance  of  sensation,  the  affection  of  the 
skin,  especially  where  exposed  to  the  light — mild  in 
dementia  precox  on  the  scalp,  face  and  neck,  conspicu- 
ous in  pellagra — and  in  the  loss  of  weight  and  strength. 
(8)  The  mental  symptoms  are  so  similar  that  most  of 
the  patients  entering  the  institutions  for  the  insane  in 
Illinois  were  diagnosed  as  dementia  precox.  (9)  In 
both  diseases  the  impressions  received  by  all,  or  by 
some  of  the  five  senses,  are  markedly  distorted.  (10) 
There  is  a  remarkable  perversion  of  the  salivary  secre- 


128  ESS.  1  VS. 

tlons  in  both  diseases  and  we  believe  of  other  gastro- 
intestinal secretions,  and  as  a  result  a  new  plankton 
naturally  appears  in  the  mouth,  ofttimes  resulting  in  a 
rapid  destruction  of  the  teeth.  (11)  Both  diseases  are 
attended  by  significant  changes  in  the  blood.  There  is 
always  a  leucocytosis  and  often  a  polycythemia 
(Bullig).  (12)  In  both  diseases  there  is  a  rari tying 
osteitis  verging  toward  osteomalacia  or  fragilis  ossium. 

If  one  reads  Chapter  Y,  pp.  147-181  of  Lavender 
and  Babcock's  edition  of  Marie's  Pellagra  (Columbia, 
S.C.,  1910),  he  can  see  many  other  parallels  between 
these  two  diseases,  but,  for  our  purposes,  the  preceding 
ri.cital  is  adequate. 

From  very  early  times  pellagra  has  been  attributed 
to  polenta  made  from  spoiled  corn,  just  as  kakke  has 
been  attributed  to  a  rice  diet.  No  consideration  of  the 
etiology  of  pellagra  nor  of  the  etiology  of  adolescent 
insanity  can  neglect  the  dietetic  metabolism.  The  Illi- 
nois Commission  on  Pellagra  has  not  yet  published 
its  report,  but  rumor  has  it  that  it  has  not  incrimi- 
nated the  corn  crop  of  the  State.  There  is  every 
reason  to  believe  that  pellagra  is  encouraged  by  an  ill- 
balanced  diet  and  that  corn  often  furnishes  the  neces- 
sary disturbance  of  dietetic  equilibrium. 

The  toxi-infectious  disease  known  as  pellagra  does 
produce  insanity,  which  insanity  the  alienists  call  by 
one  or  another  of  their  clinical  names.  Among  these 
appellations  is  dementia  precox.  At  Dunning,  Peoris 
and  at  Kankakee  a  large  proportion  of  the  pellagrins 
were  set  down  previous  to  the  recognition  of  the  so- 
matic disease  as  cases  of  dementia  precox.  To  us  this 


PELLAGRA   A.\D  ADOLESCENT  INSANITY.    129 

sug^is  that  there  are  other  toxi-infectious  diseases 
besides  beriberi,  milk  sickness  and  pellagra  which  cause 
some  or  all  of  the  other  cases  of  dementia  precox  now 
looked  upon  as  of  psycho-genetic  origin,  and  that  there 
is  a  likelihood,  moreover,  of  discovering  the  identity 
of  these  diseases  and  some  methods  as  successful  ?.s  in 
the  case  of  beriberi  of  preventing  and  curing  them. 

ii. 

The  healthy  influence  of  a  rational  attitude  toward 
the  inmates  of  the  institutions  for  the  insane  which 
the  appearance  of  pellagra  brought  about,  is  manifest 
in  a  thorough  investigation  of  the  dietetic  values  01 
the  daily  ration  and  in  the  study  of  the  physical  condi- 
tions of  the  sufferers  which  has  aroused  some  thera- 
peutic interest.  To  take  a  single  instance  the  reports 
made  during  the  past  three  years  of  the  value  of  the 
transfusion  of  blood  is  significant.  The  value  of  the 
transfusion  in  hemophilia  neonatorum,  in  acute  anemia 
and  in  certain  toxic  conditions,  is  demonstrated  to  a 
practical  finish.  The  results  of  serum  therapy  in 
various  infectious  diseases  "is  an  every-day  argument. 
The  general  belief  in  the  remarkable  efficacy  of  changes 
in  the  blood  has  led  to  the  use  of  transfusion  in  mori- 
bund cases  of  pellagra. 

In  medicine,  as  well  as  in  other  departments  of 
thought,  there  are  waves  of  interest  which  come  over 
the  public  mind  from  a  combination  of  inexplicable 
causes. 

The  mind  of  the  seventeenth  century  was  alive  to  all 
the  possibilities  of  overcoming  the  hostility  of  nature. 
Thomas  Shadwell's  Sir  Nicholas  Gimcrack  in  "The 


130  ESSAYS. 

Virtuoso,"  was  given  up  to  experimentation.  He  had 
certain  sympathetic  tubes  in  his  laboratory  which  al- 
ways resonated  to  sounds  produced  in  either  one  of 
them  regardless  of  miles  of  separation.  It  was  possi- 
ble by  speaking  in  one  of  these  tubes  in  London  to 
convey  the  voice  without  defect  to  the  other  tube  in 
Cromwell  or  Newgate.  Sir  Nicholas  asserts  that  he  was 
not  quite  perfect  in  the  science  of  aviation,  but  that  he 
could  fly  as  well  as  a  bustard.  His  achievement  in  the 
transfusion  of  blood,  however,  was  a  sort  of  climax 
of  his  experimentation  and  is  of  particular  interest  to 
us  in  this  connection.  On  page  28  of  "The  Virtuoso," 
London,  1676,  he  is  made  to  say : 

Sir  Nic. — That's  frequent.  Besides,  tho',  I  confess 
I  did  not  invent  it.  I  have  performed  admirable  effects 
by  transfusion  of  blood,  to-wit,  by  putting  the  blood  of 
one  animal  into  another.  *  *  *  Why,  I  made,  sir, 
both  the  animals  to  be  emittent  and  recipient  at  the 
same  time,  after  I  had  made  ligatures  as  hard  as  I 
could,  for  fear  of  strangling  the  animals,  to  render  the 
jugular  veins  turgid  I  open'd  the  carotid  arteries  and 
jugular  veins  of  both  at  one  time,  and  so  caused  them 
to  change  blood  with  one  another. 

Sir  For. — Indeed,  that  which  ensu'd  upon  the  opera- 
tion was  miraculous,  for  the  m-angy  spaniel  became 
sound  and  the  sound  bull  dog  mangy. 

Sir  Nic. — Not  only  so,  gentlemen,  but  the  spaniel 
became  a  bull  dog  and  the  bull  dog  a  spaniel. 

A  little  farther  along  the  inimitable  Shadwell  makes 
his  Sir  Nicholas  Gimcrack  enter  the  field  of  the  alienist 
and  taking  a  madman  he  selects  the  tamest  of  all  ani- 
mals, the  sheep,  and  transfuses  sixty- four  ounces 
Haver  du  pois  weight  of  blood  according  to  his  method 


PELLAGRA   AXD  ADOLESCENT  INSANITY.    131 

from  the  one  to  the  other,  with  the  remarkable  result 
that  the  maniac  becomes  ovine  not  to  say  sheepish,  in 
his  disposition  and  conduct.  This  operation  produced 
no  unfavorable  results  upon  the  maniac  except  the 
growth  of  a  few  adventitious  tufts  of  wool,  but  it 
proved  fatal  to  the  devoted  sheep. 

We  were  interested  to  see  what  could  have  aroused 
in  the  fertile  brain  of  Shadwell  such  a  conception  and 
were  delighted  to  find  that  there  were  numerous  in- 
stances of  similar  experiments  recorded  in  the  litera- 
ture of  the  time.  To  be  particular,  there  was  a  small 
duodecimo  emitted  "da  Emilio  Marie  Manslessei," 
Bologna,  1668,  with  the  following  prophetic  and  sig- 
nificant title : 

Relasione  dell'  esperienze  fatte  in  Inghiltcrre,  Fran- 
eta  cd  Italia  intorno  alia  celcbre  c  famosa  transfusions 
del  sangue  per  tut  to  inaggio  1668.  In  cui  oltre  all'  ap- 
pugnatiom,  a  difese,  si  vede  la  sanita  restituita  ad  al- 
ctfni  inferni,  e  particolarmente  a  un  pazzo.  La  maniera 
di  facilmcnte  pratticarla  negli  huotnini,  c  la  rninuta 
descripzione;  di  essa,  con  nuova,  esperiensa  in  un  cane 
z'ccchio,  e  sordo  restitidtio  alia  forza,  e  ndito. 

It  is  possible  that  Shadwell  had  seen  this  and  other 
similar  theses. 

But  to  return  to  the  real.  The  trend  of  modern 
hematology  leads  us  to  hope  for  a  therapeusis  which 
but  a  few  years  ago  would  have  been  looked  upon  as 
Quixotic. 

Through  the  kindness  of  Drs.  Lewis  Pollock  and 
F.  B.  Clark  I  am  permitted  to  give  here  an  outline  of 
the  results  of  transfusion  of  eleven  moribund  cases 


132  ESSAYS. 

of  pellagrous  insanity  at  Dunning.  This  work  was 
interrupted  by  the  rampages  of  a  political  bull  in  a 
china  shop.  These  pioneer  adventures  will  be  reported 
in  full  by  the  investigators,  and  only  with  such  a  full 
report  can  their  value  be  assessed;  they  are  about  as 
successful  as  the  appendectomies  of  1886-7. 

1.  Minnie    M.,    thirty-five,    pellagra    sine    pellagra, 
melancholia,  diarrhea,  comatose,  moribund,  transfused 
April  27,  1910.     Blood  of  recovered  pellagrin.     Died 
thirty  hours  later. 

2.  Mary  O'C.,  twenty-eight,  pellagra,  dementia  pre- 
cox,  diarrhea,  emaciation,  great  weakness,  transfused 
July  13,  1910;    recovery,  mental  condition  unchanged. 

3.  Nellie   S.,   pellagra,   dementia   precox,   diarrhea, 
emaciation,  transfused  August  8,  1910;  recovery,  men- 
tal betterment. 

4.  Louise  G.,  thirty-five,  pellagra,  dementia  precox, 
dysentery,  stupor,  bed  sores.     Transfused  August  26, 
1910.     Died  thirty-five  hours  after  operation. 

5.  Rosa  S.,  fifty,  pellagra,  stupor,  dysentery,  mori- 
bund.    Transfused  September  20,  1910.     Died  fifteen 
days  after  transfusion. 

6.  Sarah    R.,  thirty-seven,  pellagra,  dementia    pre- 
cox, dysentery.      Transfused  January  5,  1910.      Re- 
covery. 

7.  Thomas  O'H.,  thirty-four,  pellagra,  paresis,  dys- 
entery; polycythemia,  a  febrile.      Transfused  October 
1,  1910.    Died  seven  days  later. 

8.  Anna  L.,  twenty-seven,  pellagra,   dementia   pre- 
cox, febrile,  leucocytosis,  nephritis,  exhaustion,  dysen- 
tery.    Transfusion  in  a  remission  of  septic  symptoms. 
Death  twelve  hours  later.     Shiga  bacillus  dysentery. 

9.  Justina  K.,  forty-eight,  pellagra,  dementia  precox, 
afebrile,   asthenic,   edematous.   polycythemia.      Trans- 
fusion August  18,  1910.     Rapid  recovery. 

10.  Lena  S.,  pellagra,  delusions,  stomatitis,  emacia- 


PELLAGRA   AND  ADOLESCENT  INSANITY.    133 

tion,  diarrhea,  asthenia,  temperature  101°.  Transfu- 
sion October  13,  1910.  Rapid  recovery.  Died  ten  days 
later  of  acute  pneumonia. 

On  the  same  day  the  emittent  died  of  pneumonia 
also,  and  one  may  very  well  consider  the  possibility  of 
her  having  had  the  pneumococci  in  her  blood  which  she 
gave  out  to  the  recipient  for  the  cure  of  the  pellagra, 
but  to  the  detriment  of  both,  as  they  came  down  and 
died  of  pneumonia  upon  the  same  day.  This  would 
indicate  the  desirability  of  making  a  blood  culture  from 
the  emittent. 

11.  David  \Y.,  thirty-five,  pellagra,  depression,  ema- 
ciation, stomatitis,  salivation,  asthenia,  red  3,200,000, 
whites  8,000.  Transfusion  August  3,  1910.  Died  six 
days  later. 

Every  one  of  these  patients  was  in  such  a  condition 
that  death  was  impending.  After  the  transfusion  im- 
provement followed  in  five  cases,  and  all  but  one  of 
them  recovered.  This  one  (10),  Lena  S.,  died  of  a 
pneumococcus  pnuemonitis  on  the  same  day  that  the 
donor  died  of  the  same  condition. 

There  are  several  things  to  be  considered  in  this 
adventurous  procedure.  The  young  men  who  worked 
together  for  its  accomplishment  used  the  remedy  only 
when  all  possible  hope  of  improvement  by  expectant 
or  other  methods  had  been  abandoned  by  every  one 
concerned  and  the  patients  themselves  were  in  ex- 
tremis. They  undertook  a  surgical  procedure  requir- 
ing the  greatest  delicacy  and  a  technical  experience 
which  nothing  but  the  vivisection  room  could  give. 
They  were  working  under  the  stress  of  political  criti- 
cism and  newspaper  publicity,  and  without  the  support 


134  ESSAYS. 

of  academic  and  professional  sentiment.  The  results 
are  gratifying  and  promising,  but  they  probably  dis- 
close possibilities  of  error  and  danger  which  can  be 
eliminated  only  by  the  most  intimate  team  work  be- 
tween the  physiological  laboratory,  the  hemolitic  lab- 
oratory and  the  surgical  operating  room. 

Sambon's  recent  surmise  of  the  relation  between  the 
simulium  and  pellagra  may  or  may  not  be  sustained, 
but  it  is  certain  that  a  considerable  portion  of  the 
insane  in  the  Mississippi  valley  will  be  subjected  to 
rational  observation  and  removed  from  the  etiologic 
category  of  the  psychogenetically  insane. 

If  the  conservatism,  inactivity  and  self-complacency 
of  the  keepers  of  the  insane  can  be  disturbed  by  the 
advent  of  pellagra,  it  may  be  looked  back  to  as  a  bless- 
ing in  disguise,  and  although  the  methods  of  the  psy- 
chiatrists are  revolutionized  thereby,  it  may  place  an- 
other portion  of  the  dark  continent  of  clinical  medi- 
cine into  the  orderly  and  subjugated  domain  of  rational 


THE  LABORATORY  FOR  PSYCHIATRY. 


BY  THE  USE  of  no  mathematical  formula,  by  the  jug- 
gling of  no  syllogistic  method,  but  by  the  argument 
of  clinical,  biological  and  historical  analogy,  the  impor- 
tance of  studying  the  physical  basis  of  the  insanities 
has  been  set  forth  in  these  pages.  Not  a  tenth 
part  of  our  evidence  and  argument  of  this  sort 
has  been  utilized,  but  enough  to  lead  any  open-minded 
student  of  clinical  pathogy  and  pathological  histology 
to  predict  that  a  great  mine  of  tangible,  priceless  and 
promising  pathology  lies  buried  in  the  institutions  for 
the  insane.  Far  be  it  from  us  to  disparage  the  value 
of  re-education  and  habit  culture,  far  be  it  from  our 
conception  of  research  to  neglect  the  influence  of  men- 
tal attitude  and  mental  activity  on  bodily  functions, 
far  be  it  from  us  to  separate  mental  activity  from 
other  functions  of  the  body;  but  still  we  insist  that 
the  insanities  are  shown  by  all  analogy,  and  not  by 
the  paradigm  of  one  condition,  to  be  the  result  of  phys- 
ical conditions — conditions  that  may  not  be  discern- 
ible on  the  post-mortem  table,  that  may  not  be  visi- 
ble under  the  microscope,  that  may  give  no  reaction 
to  present-day  methods  of  research  in  the  test-tube, 
but  conditions  that  the  ingenuity  of  the  human  brain 
and  the  cunning  of  the  human  hand  are  abundantly 
able  by  rational,  existing  or  yet  to  be  discovered 
methods,  to  make  clear  and  put  under  rational  treat- 
ment and  rational  means  of  prevention. 

We  would  claim,  then,  that  it  is  the  duty  of  the 
State  into  whose  care  almost  a  quarter  of  a  million 

135 


136  ESSAYS. 

of  citizens  have  been  legally  placed,  to  provide  labo- 
ratories for  psychiatry — laboratories  to  discover  the 
causes  and  develop  cures  and  suggest  preventive 
measures  for  conditions  that  now  absorb  millions  in  a 
worse  than  hopeless  custody.  It  is  the  economic  and 
humane  duty  of  the  State  that  wastes  a  largess  of 
millions  on  the  insane,  to  establish  laboratories  for 
the  study  of  the  ailments  that  bring  so  many  of  them 
to  this  deplorable  pass,  laboratories  equal  in  every  re- 
spect, in  equipment,  in  resources,  in  faculty  and  in  per- 
manency of  position,  to  the  laboratories  of  the  Agricul- 
tural Department,  established  for  the  study  of  the 
diseases  of  animals  and  plants.1 

Our  notion  of  a  laboratory  or  institute  of  psychi- 
atry does  not  contemplate  the  erection  of  buildings 
or  the  importation  of  apparatus  and  directors.  Sev- 
eral States  have  already  built  houses  called  by  some 
such  suggestive  names.  The  laboratory,  in  our  sense,  is 
not  a  place  or  plant,  but  a  function  or  activity.  It  is 

/ 

1.  From  "Statement  of  Balances,  Appropriations  and  Dis- 
bursements of  the  Government,  for  the  fiscal  year  ending 
June  30,  1909,"  we  learn  that  for  the  Agricultural  Depart- 
ment the  following  disbursements  were  made  for  1909 :  Sal- 
aries, $1,044,812;  library,  $15,902;  contingent  expenses,  $91,- 
128;  bureau  of  animal  industry,  $1,326.452;  eradicating  cattle 
tick.  $235,627;  meat  inspection,  $3,098,760;  bureau  of  plant  in- 
dustry, general  expenses,  $933,038;  cotton  boll-weevil  investi- 
gation, $17,060;  forestry  service,  general  expenses,  $3,173,404; 
agricultural  experiment  stations,  $1.372,776;  weather  bureau, 
$1,500,000;  various  items,  raising  the  grand  total  disburse- 
ments of  the  Agricultural  Department  to  $16,282,468.  No  one 
would  criticize  these  expenditures  nor  would  any  one  with  an 
eye  for  real  economy  doubt  the  sound  sense  of  the  several 
undertakings.  The  trifling  $16,000,000  seems  stingy  when 
compared  with  $161,000,000  for  pensions,  another  $161,000,000 
for  total  military  establishment  and  $115,000,000  for  net  total 
naval  establishment. — Loc.  at.  p.  77,  121,  129',  155. 


LABORATORY  FOR  PSYCHIATRY.  137 

i  system  of  warfare  upon  a  special  scrt  of  inimical 
ignorance,  the  results  of  which  are  more  disastrous 
than  a  perpetual  international  war.  For  this  warfare 
upon  ignorance  a  concerted  systematic  research  is  neces- 
sary, carried  on  by  a  well  organized  army  of  scientific 
scouts  and  biochemical  sharpshooters.  That  equip- 
ment and  shelter  are  necessary  is  axiomatic,  but  the 
efficiency  of  such  an  army  depends  more  upon  person- 
nel than  on  mounting  and  more  upon  a  deep-seated 
humanity  and  devotion  to  scientific  service  than  to 
salaries,  honors  or  monuments. 

These  laboratories  should  be  established  in  each  of 
several  States  and  by  the  general  government  in  the 
District  of  Columbia  and  the  dependencies,  in  the  re- 
sponse to  dictates  of  obvious  duty  and  economy,  and 
in  the  hope  that  somewhere  the  right  combination 
will  be  made  that  will  open  the  door  to  the  discovery 
of  some  of  the  causes  of  the  insanities.  These  labo- 
ratories need  not  be  assembled  in  one  place  nor  be 
complete  in  each  of  the  several  institutions,  but  so 
systematized  a"nd  located  as  to  form  a  unit  regard- 
less of  locality  and  dictated  by  considerations  of  effi- 
ciency, opportunity  and  propinquity  of  material. 

The  system  of  laboratories  should  be  designed  to  ac- 
complish three  related,  perhaps  inseparable,  but  quite 
distinct  purposes : 

I.  The  first  function  of  this  laboratory  system  has 
been  well  tried  out.  It  is  found  in  the  clinical  labo- 
ratories of  all  metropolitan  hospitals.  These  labora- 
tories are  service  laboratories  to  the  institutions  in 
which  they  are  located.  Beginning  as  small  laboratory 
tables  with  a  microscope  and  a  few  reagents,  they  are 


138  ESSAYS. 

now  complicated  series  of  chemical,  bacteriological, 
hemolytic  and  physical  laboratories  requiring,  for  a 
hospital  of  two  hundred  patients,  a  floor  space  hardly 
less  than  2,000  square  feet,  and  equipment  of  elec- 
trical, optical,  chemical  and  other  apparatus  not  far 
short  of  $5,000.  The  uninformed  layman,  the  average 
doctor  of  medicine  and  even  a  member  of  a  "board  of 
control"  may  presume  that  every  institution  for  the 
insane  of  1,000  or  more  patients  would  certainly  have 
a  laboratory  of  this  sort.  It  might  be  hard  to  convince 
such  a  one  that  these  equipments  were  not  the  rule. 
Our  experience  must  have  been  exceptional  if  any  in- 
stitution for  the  insane  in  the  Mississippi  valley  has  an 
active  laboratory  comparable  in  efficiency  and  service 
with  that  of  the  average  metropolitan  hospitals  of 
the  States  in  which  they  are  located.  One  institution 
of  more  than  1,000  patients  did  not  have  a  function- 
ating microscope  for  several  months.  One  psycho- 
pathic institute  did  not  have  a  microscope,  a  manom- 
eter or  an  urinalysis  outfit  in  the  institution.  It  was  as 
devoid  of  diagnostic  instruments  of  precision  as  a 
Christian  Science  temple.  Another  institute  was 
equipped  with  all  the  instruments  that  are  listed  in 
the  catalogue,  with  unimpeachable  laboratory  tables, 
sinks,  cages,  cabinets,  dark  rooms,  incubators  and  lit- 
erature, but  not  a  single  urinalysis,  Wassermann  or 
bacteriologic  examination  was  going  on  or  had  been 
going  on  since  the  appropriation  for  equipment  was 
expended.  Such  a  condition  is  inconceivable  as  well 
as  incredible  until  it  is  rudely  and  lamentably  discov- 
ered. 

The  first  local   function  of  the  laboratory  should 


LA  BORA  TOR  Y  FOR  PSYCHIA  TR  Y.  139 

also  include  the  well-tried  methods  and  functions  of 
a  board  of  health.  The  population  of  one  of  our  State 
institutions  is  equal  to  that  of  a  small  city.  The  lab- 
oratory should  actively  care  for  the  health  of  this 
community  by  food  inspection,  by  watching  the  condi- 
tion of  the  water  supply,  by  vigilant  supervision  of 
the  plumbing  and  sewerage  disposal,  by  perpetual 
care  of  the  ventilation  and  by  advice  in  the  location, 
planning  and  construction  of  buildings.  The  daily 
ration  should  be  a  constant  care  of  the  laboratory,  and 
the  kitchen,  the  pantry,  the  toilet-rooms  as  well  as 
the  storeroom  should  receive  a  daily  vise  from  the  lab- 
oratory of  no  perfunctory  sort. 

It  is  not  supererogation  to  say  that  this  laboratory 
should  hold  guard  over  the  incoming  patients  and  at- 
tendants, and  see  to  it  that  no  extraneous  disease  is 
brought  into  the  wards  or  dormitories.  The  Wasser- 
mann  may  be  a  hardship  if  applied  as  a  routine,  but 
that  State  hospital  is  not  worthy  the  name  if  the  hem- 
olytic  tests  can  not  be  promptly  and  skillfully  made 
to  determine  the  syphilitic  or  non-syphilitic  condition  of 
patients  and  attendants.  Many  an  epidemic,  after- 
wards traced  to  a  diseased  attendant,  could  have  been 
averted  by  the  proper  inspection  of  attendant's  and 
patient's  blood.  The  typhoid  carrier  is  no  myth.  In 
one  series  of  "sporadic"  cases  which  were  studied 
with  unusual  care,  more  than  one-fifth  were  found  to 
have  sprung  from  contact  with  typhoid  carriers.  There 
is  every  reason  to  believe  that  the  application  of  the 
Widal  reaction,  together  with  a  careful  study  of  the 
anamnesis  would  lead  to  the  elimination  of  a  large 
part  of  this  danger. 


140  ESSAYS. 

II.  The  second  function  of  the  laboratory  should 
be  the  educational  function.  This  function  is  the  prin- 
cipal one  undertaken  at  New  York,  at  Ann  Arbor 
and  at  Kankakee.  In  all  these  institutions  or  labora- 
tories this  education  is  confined  to  the  training  of  the 
physicians  on  the  civil  service  lists.  This  is  a  matter 
of  no  small  concern.  These  men  in  Illinois  at  least 
are  to  be  grouped  in  two  classes,  the  passive  hold- 
over men  who  have  slept  in  the  bed  of  institutional- 
ism  for  years,  ignorant  of  the  rapid  advances  in  path- 
ology, in  sociology,  and  even  in  "the  practice  of  med- 
icine," and  a  lot  of  active  young  medical  graduates, 
poor  and  starved,  but  alive  to  a  possible  enthusiasm 
in  a  worthy  work  if  led  by  an  inspired  prophet  of 
science.  They  know  nothing  of  institutionalism  or 
its  dangers ;  nothing  of  the  possibilities  of  medical 
research.  They  have  never  practiced  medicine  on  the 
sick  for  their  cure,  and  they  have  never  seen  an  in- 
sane person  except  leaving  or  entering  the  patrol 
wagon,  which  is  used  for  an  ambulance  in  taking  the 
insane  to  and  from  the  court  at  which  they  are  tried 
and  committed  to  the  State  hospital.  They  have  heard 
kctures  and  they  have  had  quizzes  on  insanity  as  they 
might  have  had  on  the  resurrection  of  the  dead,  but 
they  have  had  no  more  experience  with  one  than  with 
the  other. 

There  is  every  reason  to  bring  these  two  elements 
that  must  eventually  work  together  into  classes  for 
some  sort  of  amalgamation,  or,  at  worst,  conglomera- 
tion. Too  often  the  baser  element  prevails  and  dom- 
inates the  service  ever  after  with  its  fateful  pes?i- 
mism.  Not  enough  can  be  said  for  the  difficulties 


LABORATORY  FOR  PSYCHIATRY.  141 

before  the  faculty  that  would  enthuse  the  whole  state 
service  with  such  an  esprit  de  corps  as  that  of  the 
army  or  navy — a  devotion  as  serious  and  profound  as 
that  of  the  early  Franciscans. 

But  it  is  not  enough  that  the  custodians  of  the  in- 
sane should  be  instructed  in  psychiatry.  There  are 
two  distinct  classes  of  medical  men  who  should  be 
brought  to  the  institute  or  laboratory  and  instructed 
by  direct  contact  with  the  insane,  namely,  the  medi- 
cal students  before  graduation  and  the  physicians  prac- 
ticing in  the  State.  At  the  present  time  there  are  no 
facilities  for  instructing  either  class,  and  in  Illinois 
there  is  a  rule  designed  to  prohibit  a  medical  society 
from  meeting  in  the  rooms  of  an  institution  for  the 
insane  or  the  exhibition  of  patients  for  clinical  pur- 
poses.1 It  would  be  a  decided  advantage  to  the  citizens 
of  the  State  of  Illinois  if  their  physicians  understood  all 
that  is  possible  of  the  insanities.  It  might  relieve  the 
State  treasury  of  some  burden  if  they  knew  what  they 
could  learn  by  a  quarterly  meeting  at  the  institutions 
where  all  the  insane  are  in  custody.  It  is  as  irrational 
to  make  the  clinical  use  of  the  insane  a  misdemeanor 
as  it  was  irrational  for  our  ancestors  to  make  the  dis- 
section of  the  human  body  a  crime. 

It  is  useless  to  say  that  this  education  should  be  a 
part  of  the  State  system  of  public  instruction,  and 
therefore  a  department  of  the  university.  That  is  to 
say,  this  educational  function  of  the  laboratory  or  in- 
stitute should  be  directly  under  the  wing  of  the  uni- 

1.  Resolution  of  the  House,  Illinois  Legislature,  under 
Speaker  Shurtliff,  1899.  relation  to  meetings  of  Fox  River 
Medical  Society  at  Elgin  Hospital  for  the  Insane. 


142  ESSAYS. 

versity  and  share  in  the  enthusiasm  and  spirit  of  the 
faculty  of  that  institution  with  all  the  possibilities 
of  libraries,  laboratories,  fellowships  and  scholastic 
recognition  ^which  university  positions  afford.  The 
horizon  of  the  university  is  unconfined  by  language, 
race,  space  or  time.  From  its  faculty  men  would 
surely  come  forth  who  would  place  the  management  in, 
a  position  to  do  for  the  insane,  for  the  citizens  of  the 
State  and  for  the  much-loved  taxpayer  the  wise  and 
right  thing. 

III.  The  third  function  of  the  laboratory  is  the  one 
on  which  all  our  hopes  are  placed ;  it  is  the  function 
of  original  research.  The  problems  of  the  insanities 
have  not  attracted  their  share  of  attention  from  fel- 
lows in  the  universities  or  from  the  candidates  for 
the  doctor's  degree  in  medicine.1  We  have  seen  yel- 
low fever  yield  to  the  assault  of  well-directed  research 
founded  on  considerate  theory.  We  have  seen  the 
long-sought  pathologic  cause  of  syphilis  come  into  the 
field  of  our  microscope,  and  more  than  that,  yield  us 
an  indubitable  hemolytic  test,  and  in  the  same  decade 
surrender  to  a  single  dose  of  a  specific  remedy.  We 
have  seen,  moreover,  the  sleeping  sickness  and  kala 
azar  come  from  the  fastness  of  the  tropics  and  sur- 
render to  the  cunning  of  wit  and  the  strength  of  a 
mosquito  bar.  There  are  more  reasons  for  investi- 
gating the  sources  of  insanities  that  place  a  quarter 
of  a  million  of  our  citizens  of  every  class  in  a  hopeless 
public  custody  than  there  was  for  the  study  of  these 

1.  Less  than  3  per  cent,  of  the  theses  of  the  medical  stu- 
dents at  Paris  were  on  the  insanities  during  the  last  three 
available  years. 


LABORATORY  FOR  PSYCHIATRY.  143 

diseases  of  the  tropics.  As  the  problem  of  syphilis 
was  solved  with  the  solution  of  the  sleeping  sickness 
problem,  so  we  may  hope  that  by  such  methods  as 
have  been  successful  in  remote  or  rare  conditions,  the 
ever-present  ignorance  of  the  sources  of  the  insani- 
ties may  be  dispelled. 

The  research  worker  must  have  a  laboratory,  but  it 
may  not  be  necessary  for  him  to  do  his  work  in  the 
institution  to  which  he  is  attached.  There  must  not 
only  be  freedom  to  think  and  investigate,  but  an  open 
choice  of  place  to  work.  The  institutions  can  not  from 
the  very  nature  of  the  case  have  more  than  "working 
laboratories."  The  university  and  the  great  libraries 
of  science  must  be  consulted  freely  and  readily.  The 
combination  which  will  open  the  door  to  the  thou- 
sands confined  in  our  asylums  might  be  in  the  hands  of 
some  investigator  but  for  one  factor  which  lies  buried 
in  the  proceedings  of  an  obscure  society. 

It  is  not  in  numbers  that  we  must  rely  in  our  search 
for  the  sources  of  the  insanities,  but  in  order  to  raise 
up  one  Pasteur,  one  Koch,  one  Metchnikoff,  one 
Khrlich,  one  Flexner  or  one  Hektoen  we  must  give 
free  hand  and  space  to  an  army  of  aspirants.  A  State 
with  15,000  wards  ought  to  provide  for  one  hundred 
laboratory  workers,  of  whom  perhaps  one-tenth  would 
be  fit  for  research.  Could  we  have  an  enthusiastic  di- 
rector, alive  to  the  need,  with  faith  in  human  cunning, 
with  an  impersonal  motive,  a  generous  intuition  and 
sympathy  and  an  indefatigable  industry  and  patience, 
there  would  center  about  him  from  the  stream  of  un- 
ernbittered  young  life  pouring  out  of  the  university,  a 
fellowship  of  students,  servants  and  investigators  that 


144  ESSAYS. 

would  make  his  laboratory  as  well  known  as  any  that 
the  rich  history  of  the  last  sixty  years  has  recorded. 

The  practical  difficulties  of  establishing  such  labora- 
tory systems  under  joint  patronage  of  the  university 
and  charities'  board  are  exaggerated  by  the  timidity 
and  lack  of  faith  of  the  custodians  of  the  insane  and 
by  the  repugnance  with  which  the  scholastics  view  in- 
sanity and  the  crimes  of  the  near-insane.  The  public 
alone,  with  a  well-fixed  public  opinion,  can  sweep  away 
these  technical  difficulties  in  a  moment.  It  is  unfor- 
tunate that  few  institutions  for  the  insane  are  in  prox- 
imity with  the  university.  The  University  of  Wiscon- 
sin, which  has  always  shown  a  helpful  spirit  in  ways 
unconventional  to  traditions  of  the  university,  has  an 
unusual  opportunity  to  work  out  problems  of  the  in- 
sanities in  the  State  asylum  almost  on  the  campus. 
For  the  most  part,  dictated  by  accidental  motives  of 
greed  or  economy  or  political  expediency,  the  State  in- 
stitutions are  placed  in  lonely  isolation.  It  is  difficult 
to  say  how  much  this  isolation  has  retarded  research 
and  degraded  the  service.  Its  influence  has  been  bad 
and  is  likely  to  be  worse.  Man  is  a  social  being.  The 
medical  and  scientific  staff  on  an  institution  is  not  alone 
depressed,  disheartened  and  enervated  by  the  enormity 
of  the  problem  before  them  and  overcome  by  the  ac- 
tual numbers  of  the  insane,  but  they  are  dragged  still 
further  down  by  the  attendant  population,  a  class  of  de- 
vitalized if  not  deteriorating  nincompoops  foisted  on 
the  service  by  the  lowest  sort  of  political  preferment. 
How  can  a  dozen  doctors  maintain  an  esprit  de  corps 
in  a  population  of  2,000  lunatics  and  1,000  time-serv- 
ing incompetents  ? 


LABORATORY  FOR  PSYCHIATRY.  145 

The  presence  of  surrounding  physicians  at  quarterly 
medical  societies,  the  quartering  in  the  asylum  of  a 
bunch  of  medical,  chemical,  bacteriological  and  other 
technical  students  from  the  classes  of  the  university, 
would  not  only  raise  the  esprit  de  corps,  but  would  fur- 
nish an  unaccredited  espionage  more  efficient  than  an 
annual  legislative  investigating  commission.  The  med- 
ical services  of  the  institutions  would  be  vitalized  by 
the  proper  extension  of  the  educational  features  of  the 
laboratory.  The  possibility  of  research  depends  upon 
the  revival  of  a  new  devotion  to  the  rescue  of  the  in- 
sane. 

The  civil  service  restrictions  are  perhaps  the  most 
difficult  to  overcome.  Their  categorical  examinations 
are  of  such  a  mesh  that  no  genius  can  ever  break  into 
the  service  of  the  State.  Civil  service  bound  China 
for  two  thousand  years  or  more.  We  are  entering  into 
civil  service  bondage,  out  of  which  no  nation  has  been 
successfully  emancipated.  It  has  all  the  heart-sick- 
ening limitations  for  the  servants  of  the  State  that  the 
captains  of  capitalistic  industry  have  imputed  to  the 
citizens  under  socialism.  'But  civil  service  might  de- 
part from  the  categorical  examination  and  allow  qual- 
ity in  the  place  of  quantity  to  count.  Under  the  uni- 
versity the  civil  service  lists  might  be  avoided  for  the 
acceptance  of  research  men  and  women. 

In  the  matter  of  research  the  friends  of  the  insane 
who  have  the  resources  could  well  initiate  the  investi- 
gation of  the  problems  of  the  insanities  by  establishing 
scholarships  in  the  great  universities,  with  prizes  for 
work  done.  It  would  be  a  worthy  monument  to  a  lost 
husband,  wife,  son,  daughter,  brother,  sister,  father  or 


146  ESSAYS. 

mother,  to  place  in  the  hands  of  some  university  a 
helpful  stimulus  to  the  study  of  the  physical  bases  of 
the  several  insanities. 

The  insane  themselves  are  in  a  helpless  position ;  the 
custodians  of  the  insane  are  hopeless  of  any  possibil- 
ity of  betterment;  the  politicians,  the  legislatures  and 
the  mass  of  the  people  are  ignorant,  not  to  say  care- 
less ;  it  remains  for  the  friends  of  the  insane  to  bring 
their  case  into  the  court  of  public  opinion  and  demand 
that  facilities  be  offered,  plans  be  instituted,  to  dis- 
cover the  diseases  or  conditions  that  lie  at  the  bottom 
of  the  insanities. 


EDUCATIONAL  AND  SOCIAL 


THE  SOUL  OF  MEDICAL  EDUCATION. 


THE  progress  in  medical  education  in  the  United 
States  during  the  last  fifty  years  has  been  most  re- 
markable and  inspiring.  It  may  be  divided  into  two 
distinct  periods,  that  prior  to  1890,  in  which  the  pre 
ceptor,  the  seven  fundamental  branches  and  the  quiz 
predominated,  and  that  subsequent  to  1890,  in  which 
the  laboratory,  the  extended  course  of  study  and  the 
multiplied  written  examinations  prevail.  In  the  for- 
mer period  the  time  of  study  was  not  rhore  than  eigh- 
teen months ;  in  the  latter  it  is  not  less  than  thirty 
six. 

This  change  has  not  in  every  sense  been  progress. 
Unity  has  been  sacrificed  for  unrelated  multiplicity, 
quality  for  quantity  and  diversity  for  intensity.  The 
diet  has  been  varied  and  the  service  complicated,  but 
the  cooking  has  deteriorated.  The  course  of  study 
now  covers  four  years  of  nine  months  each,  and  the 
student's  work  is  measured  in  thousands  of  hours 
divided  into  hundreds  of  hours  in  each  department. 
There  is  no  co-ordination  of  the  studies  in  the  sev- 
eral departments.  While  the  clinical  work  is  in  ob- 
stetrics, the  laboratory  work  is  on  the  anatomy  of 
the  brain  and  the  lectures  on  ulcer  of  the  stomach. 
Thus  the  student  cannot  have  his  mind  and  his  work 
on  any  single  topic  continuously.  All  concentration 
and  intensity,  as  well  as  all  completeness  and  pro 
fundity  are  unattainable. 

The   student   "must   pass"    forty   different    subjects 
149 


150  ESSAYS. 

and  an  equal  number  of  men.  and  this  passing  must 
be  done  in  one  definite  way  (usually  by  a  written  ex 
animation)   at  one  particular  time  and  in  one  partic 
ular  place. 

There   is   no   "residence"   in   a   medical   school   to 
day.     In  olden  times  a  man  could,  and  frequently  did, 
go  to  a  medical  school  and  take  in  the  spirit  of  clinical 
study  and  medical  research.     He  knew  one  or  more 
of  his  professors  well  and  got  the  torch  of  inspira- 
tion handed  down  to  him  in  a  direct  line   from  the 
altar  of  /Esculapius.    He  learned  only  a  small  amount 
of  medicine,  but  he  knew  how  little  it  was ;  he  di- 
gested it  and  was  hungry  for  more.     He  went  home 
possessed  with  a  hunger  for  medical  know-ledge.    To- 
day our  students   rarely  meet   a  professor  to  know 
him  and  few  professors  have  the  sacred  ^Esculapian 
fire  to  pass  on.     If  they  have  any  inspiration  at  all 
it   is    for   business,   preferment   and   publicity    rather 
than  for  service,  for  insight  and  for  erudition.     The 
enormous  and  exacting  demands  of  the  better  class  (  ?) 
of  medical  schools  are  so  time-consuming  that  a  man 
has  no  leisure   for  mental  rumination  and  digestion. 
The    school    is    one    continuous    cram,    one    unending 
grind,  one  perpetual  hustle.     Detail,  multiplicity,  su- 
perficiality and  the  rule  of  thumb  prevail,  and  all  per 
spective,    solidity   and    erudition    are   excluded.      The 
students  go  through  the  medical  school  almost  as  pas- 
sively as  the  hides  go  through  the  factory  to  be  turned 
out  shoes. 

The  reason  we  have  the  factory  system  in  medical 
education  is  easy  to  find.     It  is  because  of  the  indus- 


SOUL   OF  MEDICAL  EDUCATION  151 

trial  tyranny.  The  public  schools  of  the  United  States 
are  under  fifty  different  autocratic  and  wholly  inde- 
pendent departments  of  education,  yet  the  methods, 
plans,  curriculum,  systems,  text-books,  equipment  and 
even  architecture  are  uniform  and  monotonous.  The 
homogeneity  of  the  republic  is  manifest  in  this  fact. 
The  German  Empire,  the  British  Isles  and  the  French 
Republic  each  present  far  greater  variations  within 
their  national  educational  systems  than  does  the  United 
States. 

In  medical  education  we  show  the  same  conform- 
ity to  a  national  ideal  that  is  so  obvious  in  the  pub- 
lic school  system.  The  several  State  boards  prescribe 
within  their  own  jurisdiction  educational  rules  and 
limitations  that  are  by  courtesy,  custom  and  economic 
interdependence  operative  in  a  whole  nation  of 
fifty  sovereign  States  and  Territories.  The  num- 
ber of  years,  months,  weeks  and  even  hours  that  the 
student  must  be  on  the  ground  as  well  as  the  curri- 
culum of  studies  are  prescribed-,  the  number  of  exam- 
inations, of  laboratory  or  dissecting  hours  and  even 
the  season  of  these  hours  are  dictated,  and  the  time, 
form  and  number  of  special  clinical  observations  set 
down  in  detail.  Such  ironclad  limitations  and  regu- 
lations do  not  prevail  in  the  medical  schools  of  mon- 
archical Russia,  imperial  Germany  or  bureaucratic 
France  as  our  self-supporting  and  absolutely  unen- 
dowed and  unsubsidized  medical  colleges  placidly 
accept. 

The  Association  of  American  Medical  Colleges, 
which  has  been  in  existence  for  twenty  years,  and 


1:2  ESSAYS. 

the  latterly  organized  Council  of  Medical  Educa- 
tion of  the  National  Association  have  each  extended 
the  sphere  of  external  influence  in  the  internal  man- 
agement of  the  medical  school  until  now  the  officers 
of  a  medical  college  are  about  in  the  position  of  a 
local  railway  station  agent  in  a  union  station  handling 
business  for  three  or  four  railways  and  receiving 
almost  daily  instructions  from  the  passengjer  and 
freight  departments  of  each  of  them  and  from  the 
State  and  National  Railway  Commissions  besides.  In 
the  multitude  of  clerical  details  the  so  personal  and  so 
intangible  spirit  of  education  is  crowded  out. 

By  an  entirely  different  force  the  energies  ''of  the 
medical  school,  are  set  to  another  task — that  of  ma- 
terial display.  Our  time  and  our  country  above  all 
others  is  possessed  by  a  frenzy  to  dazzle  by  the  os- 
tentatious manifestation  of  the  possession  of  material 
resources.  Brick  and  mortar,  marble  and  granite 
are  far  more  conspicuously  advertised  in  the  calls  for 
students  than  the  theses  or  other  achievements  of 
former  graduates  or  of  the  members  of  the  faculty 
itself.  The  essentials  of  medical  education  are  over 
shadowed  by  the  accessories.  Education  is  not  an  ac 
quisition ;  it  is  a  process.  A  medical  education  cannot 
be  given  by  a  medical  school ;  it  can  be  pursued  only 
by  a  medical  teacher  and  a  medical  student  in  the  im 
mediate  interest  of  a  patient.  The  patient  furnishes 
the  adequate  motive,  the  teacher  suggests  by  example 
and  by  precept  the  expeditious  method,  the  education 
springs  from  the  effort  of  the  student  to  relieve  or 
cure  the  patient.  Just  so  skill  and  strength  is  devel- 


SOUL  OF  MEDICAL  ED  i' CAT  I  OX  153 

oped  in  the  sailor  by  sailing  in  a  well-managed  ship. 
The  ship  is  a  secondary  matter.  A  better  sailor- may 
be  made  on  a  two-hundred-ton  whaler  than  on  a 
twenty-thousand-ton  ocean  greyhound.  It  does  not 
take  a  model  marble  Acropolis  or  a  ducal  Italian 
palace  to  keep  alive  the  fires  of  ^Esculapius,  to  arouse 
the  attentiveness  of  a  Sydenham  or  a  Kraepelin,  to 
develop  the  cunning  of  a  Pare  or  a  Parks,  or  to 
incite  the  spirit  of  martyrdom  of  a  Carroll,  of  a 
Lazear  or  of  a  Ricketts.  It  is  the  intangible  spirit  after 
all  that  marks  the  difference  between  the  professional 
doctor  and  the  successful  pill  peddler;  between  the 
alert  surgeon  who  cuts  when  he  must  and  the  deft 
operator  who  cuts  when  he  can.  It  is  that  same  in- 
tangible spirit  that  gives  all  the  honor,  position  and 
public  confidence  to  our  profession  that  makes  it  pos- 
sible for  the  graduated  and  licensed  medical  trades- 
man to  build  up  his  economic  successes  on  our  pro- 
fessional degradation  and  at  the  price  of  our  ethical 
standards. 

There  are  at  least  three  phases  of  this  intangible 
spirit  that  ought  to  be  found  in  every  medical  teacher 
— the  scientific,  the  pedagogic  and  the  professional. 
No  man  is  fit  to  be  a  medical  teacher  who  is  not  an 
enthusiastic  student.  He  should  be  acquisitive,  alert 
and  scholarly  in  his  own  educational  progress.  The 
condition  of  every  medical  subject  is  like  the  market, 
always  moving  and  always  changing.  A  man's  medical 
vigor  is  shown  by  his  productive  activities.  If  he 
produces  nothing  for  medical  progress  in  the  medical 
press  his  efficiency  and  potency  stands  questioned.  If 


15-;  AYS. 

his  name  is  not  found  in  medical  literature  it  stands 
unsupported  on  the  faculty  list.  Only  original  re- 
search fits  a  man  to  be  a  teacher.  The  medical  teacher 
ought  also  to  be  either  a  natural  or  an  educated  and 
trained  pedagogue.  The  educational  value  of  a  medi- 
cal course  ought  and  may  be  as  great  as  that  of  a 
literary  or  scientific  university  course  if  this  course 
is  conducted  with  psychologic  good  sense  and  reason. 
The  discipline  of  a  course  in  human  anatomy  ought 
to  be  as  educationally  correct  and  as  culturally  valu- 
able as  a  course  in  physiography  if  the  teachers  are 
equally  good  men  and  equally  good  pedagogues.  It 
is  the  work  of  the  student  that  educates,  the  quality 
not  the  quantity  of  his  work.  The  quality  of  a  stu- 
dent's work  rarely  rises  higher  than  his  teacher's  ideal. 

Our  medical  teachers  have  paid  too  little  attention 
to  their  methods.  They  have  tried  to  produce  para- 
gons of  knowledge,  not  enthusiasts  of  research.  They 
have  gone  over  the  subject  with  their  class  rather 
than  secured  an  excursion  of  each  member  of  the 
class  into  the  subject.  They  have  tried  to  present  the 
subject  rather  than  lead  the  student  to  a  mastery 
of  the  subject.  They  have  aimed  at  the  abstract 
rather  than  the  concrete.  Facts  have  been  magnified 
while  relations  and  methods  have  been  minimized. 
The  patient  has  been  kept  in  the  background  as  an  ab- 
stract composite  rather  than  in  the  foreground  as  the 
great  motive.  The  appeal  has  been  made  to  the  in- 
tellect and  reason  when  it  should  begin  with  the  affec- 
tions and  emotions. 

The  medical  teacher  should  be  a  member  of  the 


SOUL  C.  C  ATI  OX  155 

medical  profession  and  devoted  to  its  honor  and  its 
irterests.  He  should  not  be  in  the  pay  of  any  other 
interests,  social  or  economic,  governmental  or  secta- 
rian. The  only  pay  a  medical  man  should  accept  must 
come  from  a  grateful  patient.  Membership  in  a  med- 
ical society  does  not  make  a  professional  man  in  the 
sense  of  this  theme.  The  most  blatant  quacks  have 
been  not  only  members,  but  the  censors  of  medical 
societies.  Professionalism  is  a  matter  of  the  consci- 
ence and  the  soul.  It  is  the  ethically  educated  social 
spirit  of  the  medical  man.  A  good  doctor  is  made  of 
i<.  well-educated!  man  who  feels  deeply  the  needs  of  the 
sick  and  believes  himself  called  to  live  and  work  for 
their  cure  and  the  prevention  of  the  same  diseases  in 
the  well.  This  consecrated  man  must  be  educated  in 
all  that  the  labors  of  medical  men  in  the  past  have 
discovered  and  be  guided  onward  to  the  very  boundary 
of  our  exact  science  and  into  the  disputed  territory  of- 
ignorance  and  perhaps  of  superstition.  These  excur- 
sions should  be  led  by  a  veritable  medical  scout  who 
has  in  practice  all  the  arts  of  pioneering,  adventure 
and  discover}-.  The  motive  for  all  these  efforts  in  edu- 
cation should  be  constantly  kept  prominent  and  the 
forgetful  medical  student  should  be  tripped  by  his 
teacher  into  perpetual  consciousness  that  it  is  the  duty 
of  the  doctor  to  cure  his  patic'nt.  By  precept  and  by 
example,  in  season  and  out  of  season,  he  should  be 
educated  in  the  social  and  ethical  principles  and  tradi- 
tions of  our  profession.  Only  by  men  of  scholarly 
attainment,  pedagogic  skill  and  professional  integrity 
can  such  an  education  be  conducted. 


THE  GROWING  FUNCTIONS  OF  THE  STATE 
UNIVERSITY. 


THE  history  of  the  university  is  the  history  of  cul- 
ture. Each  age  has  its  ideal  and  each  country  modi- 
fies that  ideal  by  its  national  idiosyncrasies.  The 
oldest  of  all  universities,  the  most  influential  at  home 
and  least  modified  by  the  past  two  thousand  years,  is 
the  University  of  China,  as  exhibited  in  the  civil  ser- 
vice system  of  the  Celestial  Empire.  The  conserva- 
tism of  culture  and  erudition  was  never  more  mani- 
fest. Its  tenacity  to  precedent  is  comparable  only  to 
that  of  our  common  law  and  our  Anglo-Saxon  lawyers. 
With  us  the  university  is  as  various  as  numerous.  The 
University  of  the  State  of  New  York  most  resembles 
the  Chinese  model.  It  is  a  great,  though  as  yet  un- 
credited,  civil  service  system.  The  University  of 
Virginia  is  an  English  school  planted  in  an  English 
colony.  The  University  of  Michigan  is  a  democratic 
educational  engine,  supported  by  a  liberal  State.  The 
University  of  Wisconsin  is  all  that,  and  an  informal 
advisory  body  to  the  State  legislature.  And  so  we 
might  go  on  and  show  many  a  new  function  the  uni- 
versity has  somewhere  undertaken. 

*     *     * 

The  new  schools  which  arc  added  from  time  to  time 
to  the  sisterhood  of  colleges  that  make  up  the  univer- 
sity are  no  innovation  since  the  exclusive  circles  of 
theology,  law  and  medicine  have  once  been  invaded 

157 


15s  IYS. 

by  science.  Not  all  of  our  universities  have  schools 
of  library  science,  not  all  have  schools  of  fores- 
try, but  it  would  be  no  shock  to  the  educational 
public  to  learn  that  any  university  had  established  a 
school  of  aerial  navigation.  To  teach  anything  or 
everything  is  one  of  the  accredited  functions  of  the 
university,  to  certify  to  equipment  and  achievement 
is  another  acknowledged  function  of  the  university, 
but  to  give  advice  to  legislative  committees,  to  present 
historical,  scientific  and  cosmopolitan  vistas  of  any 
particular  subject  to  a  legislature  has  not  yet  been 
demanded  of  manv  of  our  State  universities. 


The  university  should  be  a  sort  of  conscience  of  the 
State.  When  the  annual  budget  comes  up  the  paring 
begins.  A  million  dollars  is  demanded  for  a  State 
prison,  another  million  for  asylums  for  the  defective, 
the  insane,  the  deaf  and  the  blind,  and  a  half-million 
for  a  school  of  medicine  and  a  school  of  veterinary 
science.  The  prison  will  be  built,  and  most  likely  the 
asylums  will  suffer  only  moderately,  but  the  schools 
of  science  will  be  cut  down  or  out  entirely.  If  the 
university  was  called  upon  it  would  show  to  a  way- 
faring legislator  that  the  prison  is  an  inhuman,  dis- 
graceful and  transient  monument  of  the  ignorance,  ex- 
travagance and  thoughtlessness  of  our  present  civili- 
zation, and  better  things  would  be  suggested.  The 
bulk  of  the  prisoners  are  defectives  rather  than  delin- 
quents, and  should  be  cared  for  and  cured  rather  than 
punished.  The  source  of  the  delinquent  and  vicious 


159 

defective  should  be  guarded  in  the  public  schools  and 
the  injury  to  the  individual,  to  society  and  to  the  pub- 
lic treasury  forestalled.  The  university  could  advise. 
if  it  were  called  upon  to  do  so,  that  the  sources  of  in- 
sanity, mutism  and  blindn-ess  be  studied  and  guarded 
by  such  means  as  a  thorough  knowledge  of  the  sub- 
ject suggests.  Certainly  a  goodly  percentage  of  all  the 
expenditures  for  prisons,  asylums  and  schools  of  de- 
fectives should  be  expended  through  the  university  or 
'.•thcr  bureru,  in  permanent  means  of  preventing  the 
occasion  for  these  expenditures. 

The  Department  of  Agriculture  and  its  experunent 
stations  expend  more  money  each  year  than  any  uni- 
versity in  the  world,  and  all  to  study  the  diseases  of 
cows  and  hogs,  cotton  and  corn,  and  prevent  eoc- 
nomic  loss.  Yet  it  is  one  of  the  most  effective,  be- 
nevolent and  economic  activities  of  our  Government. 
It  is  the  department  that  comes  nearest  home,  ex- 
cepting only  the  postoffice,  and  has  most  enhanced 
our  reputation  abroad. 


The  State  university  is  now  called  upon  to  educate 
to  certify,  to  investigate,  to  advise,  and  it  should  un- 
dertake to  co  ordinate  the  various  functions  of  the 
State  by  advising  the  legislative  and  executive  de- 
partments. The  department  of  sociology,  for  exam- 
ple, and  the  department  of  medicine  should  have  stu- 
dents by  the  side  of  the  students  of  the  depart- 
ments of  law  and  engineering  in  the  State  prison. 
There  they  should  investigate,  as  students  alone  can, 


160  AYS. 

the  conditions  precedent  to  the  conviction  and  suc- 
cedent  to  the  confinement  both  within  and  without 
the  convict,  each  with  the  bias  of  his  own  depart- 
ment and  training.  These  studies  should  be  consid- 
ered as  a  university  topic  for  action  in  life,  in  law 
and  in  the  development  of  the  commonwealth.  How 
easy  it  is  for  the  medical  man  to  see  why  so  many 
convicts  become  insane  and  why  such  an  excessive 
proportion  of  long-time  men  die  of  consumption.  Is 
it  as  clear  to  the  scientist  and  lawyer?  Only  the  young 
can  learn  outside  their  accustomed  routine  or  horizon. 
The  students  from  all  departments  carry  the  same  fund 
of  opinions. 

How  easy  the  medical  man  at  the  school  for  mutes 
sees  the  possibility  of  diminishing  mutism  by  prevent- 
ing epidemics  of  scarlet  fever  and  by  rational  treat- 
ment of  the  disease  for  the  prevention  of  compli- 
cations due  to  secondary  mixed  infection.  His  col- 
leagues from  other  departments  would  not  fail  to  be 
convinced  of  this.  But  why  multiply  illustrations? 


This  is  often  referred  to  as  the  age  of  specialists. 
While  there  should  be  some  reservations  and  limita- 
tions in  accepting  this  statement,  for  our  purposes  it 
may  pass.  The  university  makes  a  specialty,  then,  of 
being  consciously  wise.  This  has  been  the  specialty 
of  the  university  for  ages.  It  has  not  always,  it  does 
not  always,  impart  this  wisdom.  The  State  univer- 
sity does  not  always  use  this  wisdom  to  direct  the 
actions  of  the  State. 


UNIVERSITY'S  GROli'IXG  Fi'XCTIONS.        161 

There  are  pedagogues  who  say  doing  comes  before 
knowing.  It  is  axiomatic  that  the  knowing  that  ac- 
companies doing  is  incomparably  superior  to  a  know- 
ing without  doing.  A  university  that  does  is  far  more 
alive  than  one  which  simply  stamps  that  which  has 
been  done — one  that  certifies  to  the  doer.  The  the- 
sis was  once  the  only  evidence  of  the  doings  of  the 
university.  Now  we  have  a  Babcock  separator,  a 
system  of  cheese  making,  a  nitrogen-producing  vac- 
cination of  the  soil,  a  thousand  additions  to  our  chem- 
ical and  therapeutic  catalogue,  and  no  end  of  elec- 
trical and  optical  achievements. 

But  greater  than  all  these  we  have  the  intimate 
relation  between  the  university  and  various  depart- 
ments of  State  government  in  Wisconsin  and  Cali- 
fornia, and  the  growing  activity  of  the  university  in 
the  agriculture,  education,  mining,  manufacturing, 
transportation  and  so-called  charities  of  the  State. 


What,  then,  as  medical  men  should  we  expect  of 
the  university?  A  thoroughly  aggressive  medical 
school,  such  as  the  University  of  Michigan,  has  be- 
gun ;  an  inclusive  system  of  certification  such  as  the 
University  of  the  State  of  New  York  maintains  for 
the  degree  of  doctor  of  medicine  as  well  as  for  every 
other  scholarly  achievement ;  a  helpful  bureau  of  pre- 
ventive medicine,  a  laboratory  of  diagnosis  and  inves- 
tigation, a  department  of  sanitary  police,  such  as  the 
Board  of  Health  of  Illinois  furnishe-;,  and  a  school  or 
laboratory  in  every  institution  supported  by  the  State, 


162 

in  which  school  sources  of  the  errors  which  made  the 
institution  necessary,  are  studied  with  a  view  to  pre- 
vent them  from  arising  in  the  future. 

Every  activity  of  the  university  in  doing  what  its 
knowing  indicates  should  be  encouraged  by  every 
medical  man.  In  the  old  university,  in  the  three  col- 
leges of  theology,  law  and  medicine  the  equipment 
was  the  same,  the  sole  aim  to  teach  to  know.  The 
medical  school  was  the  first  to  break  with  tradition 
and  took  in  the  laboratories  of  chemistry  and  biology. 
For  half  a  century  the  struggle  between  the  classics 
and  the  sciences  has  been  going  on.  Now  the  strug- 
gle between  knowing  and  teaching  to  do  and  knowing 
and  teaching  by  doing  is  just  beginning.  If  the  cor- 
respondence school  and  the  local  schools  take  off 
most  of  the  burden  of  teaching  by  the  didactic 
method,  the  university  can  have  the  energy  to  serve 
the  vState  by  doing  that  which  its  prescience  may  eas- 
ily achieve.  If  the  aim  of  the  university  is  to  better 
by  its  wisdom  and  conscience  the  condition  of  the  citi- 
zen, it  may  well  follow  the  Department  of  Agriculture 
in  its  service  to  live  stock  and  food. 

*     *     * 

%  In  our  day  few  great  changes  are  made  with  the 
sound  of  trumpets,  pageants  and  acclaim.  The  new 
functions  of  the  university  are  stealing  quietly  into 
operation  and  favor.  The  experimental  farm  at  the 
university  is  not  far  from  the  antitoxin  and  vaccine 
laboratory.  The  school  of  nursing  is  not  many  steps 
from  the  school  of  medicine.  The  water  survev  is  not 


L'XirERSITY'S  GROll'IXG  FUNCTIONS.        163 

unlike  the  testing  of  the  roller-towel  habit  and  the  com- 
mon drinking-cup.  The  testing  of  herds  and  dairies 
is  not  materially  different  from  the  inspection  of 
schools  and  communities.  These  activities  are  all 
functions  of  the  State,  executed  by  those  who  know 
and  naturally  the  vested  right  of  the  university.  If 
we  are  a  people  of  such  general  integrity  and  devo- 
tion to  duty,  that  we  take  a  far-sighted  view  of  every 
activity,  then  the  university  may  become  the  conscience 
of  the  State,  and  the  public  conscience  will  be  on  the 
horizon  which  cosmopolitan  history,  scientific  prophecy 
and  a  modest  philosophy  alone  can  secure. 


WHO  PAYS  FOR  MEDICAL  EDUCATION? 


THERE  is  a  plethora  of  unfavorable  criticism,  if  not  of 
abuse,  of  the  thoroughly  disreputable  medical  college. 
Medical  education  is  bad,  just  as  bad  as  it  can  be.  In 
the  very  best  medical  school,  Johns  Hopkins,  the  curri- 
culum is  rigid,  the  methods  uncultural  and  the  student 
is  far  from  both  patient  and  teacher.  Medical  pedagogy 
is  about  on  the  same  plane  as  pedagogy  in  the  New 
England  College.  At  Harvard  and  Columbia  fche 
same  misconception  of  education  is  apparent  if  not 
glaring.  Knowledge  is  set  forth  instead  of  education. 
Equipment  rather  than  development,  results  rather 
than  power,  attainments  rather  than  intellectual  accel- 
eration, achievement  rather  than  enthusiasm  to  serve, 
a  spirit  of  judicial  pessimism  rather  than  a  fervor  for 
pioneering  adventure  and  clinical  conquest — these  are 
the  ideals  of  medical  teachers  in  the  hierarchy  of  med- 
ical schools.  The  result  is  a  highly  specialized  intel- 
lectual and  social  machine,  with  no  adequate  motive 
power,  with  no  vis  a  tergo. 

In  furtherance  of  this  cramming  process  to  the  ex- 
clusion of  education,  the  condition  of  the  students' 
previous  education  (?)  is  a  large  factor.  Most  grad- 
uates of  our  literary  schools  are  crammed,  jammed 
full  intellectually  of  undigested  and  unusable  mate- 
rial. All  enthusiasm,  all  mental  hunger,  all  spiritual 
aspiration  has  been  crushed  out  or  displaced  by  pessi- 
mistic philosophy  and  pedantic  discipline.  It  is  a 
faii.r  pas  to  be  interested  profoundly  in  anything  ex- 

165 


166  ESSAYS. 

cept  sports  and  fads.  To  be  blase  to  all  the  serious 
problems  of  life,  of  society  and  of  government  is  the 
fruition  of  modern  college  education.  The  minds 
of  these  medical  neophytes  are  morphologically  mon- 
strous, but  physiologically  as  dead  as  a  sparkless  gaso- 
line engine. 

One  of  the  most  alarming  signs  of  the  decay  of  out 
national  virility  is  the  trifling  attitude  of  the  pressed- 
brick  product  of  our  over-endowed  colleges  and  uni- 
versities. The  students  graduate  knowing  everything, 
more  than  they  want  to  know,  knowing  all  that  has 
been  said  and  done,  but  doing  and  having  done  nothing. 
and,  more  than  that,  wishing  to  do  nothing,  and  be- 
lieving that  nothing  is  worth  doing.  With  this  sort 
of  material  alone  the  best  medical  schools  deal  ex- 
clusively. 

In  the  inferior  medical  schools  the  raw  material  for 
education  is  about  as  bad.  The  high  school  is  the 
people's  college  and  apes  the  endowed  college.  The 
system  of  education  is  in  many,  though  not  all  locali- 
ties, quite  as  unpedagogic.  In  so  far,  however,  as  it 
robs  the  student  of  less  years,  it  is  less  destructive 
of  our  hopes  for  his  future  educational  possibilities  in 
medicine.  In  so  far  as  it  is  plebian  as  compared  with 
the  aristocracy  of  the  college,  the  possibility  of  a 
second  growth  of  inspiration  and  of  enthusiasm  in 
education  in  the  medical  school  may  be  occasionally 
expected.  The  very  youth  of  the  high  school  gradu- 
ate, the  unlumbered  and  unprejudiced  condition  of  his 
mind,  the  curiosity  and  spirit  of  adventure  of  the  in- 
experienced and  the  noble  sentiments  of  the  seit-re- 


WHO  r.-lVS  FOR  MEDICAL  EDUCATION?      167 

liant  and  often  self-supporting  rural  or  village  boy 
makes  him  quite  as  good  material  for  an  effective  med- 
ical education  as  the  older,  over-trained  college  grad- 
uate. 

Twenty  years  ago  the  writer  endeavored  to  att  -act 
graduates  of  the  best  colleges  and  universities  to  a 
medical  school  for  which  he  stood  sponsor.  The 
effort  was  moderately  successful,  but  none  of  Uiese 
highly  educated  men  led  their  classes  in  medical  cul- 
ture, scholarship  or  enthusiasm,  nor  did  they  subse- 
quently prove  themselves  worthy  the  attentions  and 
favors  that  were  offered  them.  Several  of  them  have 
become  salaried  servants  of  rich  exploiters  of  labor  and 
the  natural  resources  of  the  commonwealth  ;  several 
have  become  blatant  quacks,  but  the  most  of  them 
have  settled  down  to  a  commonplace  but  a  complaining 
obscurity.  Not  one  has  made  good  the  ideal  for  which 
he  was  sought,  and  the  writer  has  set  it  down  to  his 
own  long  list  of  well-meaning  blunders  that  he  dis- 
suaded so  many  men  from  careers  which  the 
have  honored  to  one  which  they  have  failed  to  ap- 
preciate. 

That  medical  schools  are  rotten,  inefficient  and  un- 
pedagogic,  we  must  all  freely  admit,  but  the  results, 
even  the  possibilities  of  any  medical  education  depend 
upon  and  are  limited  by  the  quality  of  the  education 
given  the  medical  novice  in  the  colleges,  the  high 
schoo;s  and  the  grammar  schoo's.  Until  our  whole 
public  'education  is  made  pedagogic  and  educational 
instead  of  effeminate  and  sapless  discipline,  no  great 
revolution  in  medical  schools  can  be  expected  to  ac- 


168  ESSAYS. 

complish  really  beneficial  results.  The  students  come 
to  the  lectures,  laboratories  and  clinics,  expecting  to 
be  instructed,  not  educated;  they  expected  to  be  told 
and  shown,  and  not  led  to  think  and  to  discover.  Like 
the  trees  in  a  bad  botanical  garden,  the  pathological 
specimens,  the  clinical  cases  and  the  therapeutic  meas- 
ures must  be  conspicuously  labeled.  The  whole  trick 
is  to  use  names  and  answer  questions.  Bottle-fed  in 
the  grammar  schools,  pap-fed  in  the  high  schools, 
stuffed  in  the  colleges,  they  expect  to  be  fattened  on 
predigested  nutriment  or  passively  filled  up  by  a  sort  of 
educational  stomach-tube  in  the  medical  school.  A 
successful  oarsman  for  the  lifeboat  cannot  be  made  by 
over-nutrition  and  gymnasium  machinery,  and  no 
more  the  medical  man  by  passive  methods  of  a  would- 
be  education.  When  the  novice  comes  to  the  medical 
school  after  six  or  eight  years  of  cramming,  any  seri- 
ous, active  or  strenuous  mental  and  physical  endeavor 
in  medicine  is  not  humanly  probable. 

Seven  years  ago  the  teachers  in  three  contiguous  if 
not  rival  schools,  met  to  discuss  pedagogic  methods  in 
medical  schools.  Several  men  were  present  whose 
names  lend  luster  to  American  medicine  or  American 
biology.  The  discussion  was  free,  familiar  and  radi- 
cal. The  conclusions  of  the  several  conferences  were  a 
credit  to  the  intuition  and  incisive  judgment  of  men 
used  to  looking  the  inevitable  squarely  in  the  face.  It 
appeared  to  them  that  competition  with  men  educated 
by  such  a  method  as  these  conferences  proposed  would 
put  every  one  of  the  present  medical  consultants  out 
of  business.  The  expense  of  such  education  would  be 


ll'IIO  PAYS  FOR  MEDICAL  ITIONf       169 

far  beyond  the  resources  of  the  medical  colleges.  The 
restrictions  of  State  examining  and  licensing  boards 
would  greatly  embarrass  any  college  undertaking  such 
methods.  The  conferences  were  interesting  diversions, 
but  otherwise  ineffectual,  and  are  now  forgotten  his- 
tory. 

It  is  therefore  interesting  to  compare  the  financial 
and  physical  resources  of  the  medical  schools  of  the 
United  States  with  the  resources  of  other  professional 
schools  and  the  schools  of  technology.  The  144  med- 
ical schools  of  the  United  States  reported  to  the  Com- 
missioner of  Education  (1909)  22,158  students,  of 
whom  4,484  graduated  (20  per  cent.)  ;  1,605  of  these 
students  had  college  degrees  on  entering.  The  medical 
education  was  conducted  with  equipment  valued  at 
$12,583,981,  and  by  the  help  of  endowments  of  $3,468,- 
734,  or  $156  endowment  for  each  medical  student. 
The  average  fee  of  a  medical  student  is  less  than  $200 
per  year.  The  course  of  study  requires  not  less  than 
four  years,  and  yet  a  very  considerable  proportion  of 
medical  students  take  a  hospital  interneship  requiring 
two  years  more.  The  professors  are  for  the  most  part 
unpaid,  receiving  return  for  their  time  and  labor  only 
indirectly  through  acquaintance  and  consultation.  So 
far  as  they  are  concerned,  the  medical  school  is  a  part 
of  their  bureau  of  publicity  and  promotion,  a  business 
necessity. 

The  163  theological  schools,  with  10,218  students, 
1,775  of  whom  graduated  during  the  year,  or  17  per 
cent. ;  3,335  of  those  students  had  college  degrees. 
The  buildings  and  grounds  (dormitories,  etc.)  were 


170  ESS. 

valued  at  $19,766,100,  and  the  schools  had  endowments 
amounting  to  $32,024,000,  or  $3,134  of  endowment  for 
each  theological  student.  This  does  not  include  all  the 
aids  to  theological  education  which  ought  to  be  reck- 
oned with.  Students  from  certain  districts  are  given 
additional  aid  by  local  societies  and  perquisites  follow, 
even  pursue,  the  neophyte  of  divinity  until  his  delivery 
from  the  educational  machine. 

The  meager  physical  outlay  necessary  to  a  most  lux- 
urious divinity  training  is  sufficiently  obvious,  never- 
theless $19,000,000  are  appropriated  to  the  use  of  10,- 
000  students,  or  nearly  $2,000  for  each  man. 

Every  one  who  knows  anything  about  a  medical 
school  is  appalled  by  the  enormous  expenses  connected 
with  the  laboratories,  the  dispensaries  and  the  hospital 
work  as  now  conducted.  The  ideal  would  be  far  more 
expensive.  Theological  and  legal  education  is  cheap 
compared  with  medical  training  in  actual  physical  equip- 
ment and  physical  outgo. 

The  military  and  naval  schools  are  national  institu- 
tions. The  admissions,  at  about  the  age  of  seventeen, 
are  made  by  two  radically  different  methods,  by  geo- 
graphical distribution  and  by  political  preference,  on 
the  one  hand,  and  by  rigid,  pedantic  scholastic  and 
physical  examination  on  the  other  hand.  There  are  al- 
ways vacancies  in  these  schools.  The  students  have  no 
fees  or  expenses  to  pay,  but,  on  the  other  hand,  they 
receive  $500  a  year  stipend  and  at  last  a  commission 
and  salary.  Only  the  most  elementary  military  train- 
ing is  given  at  West  Point.  This  is  supplemented  by 
a  more  technical  and  practical  training  in  army  service 


It'HO  PAYS  POR  MEDICAL   EDUCATION      171 

schools  at  Ft.  Leavenworth  and  the  engineer's  school 
and  other  special  service  schools  at  Washington  and 
elsewhere.  Qnly  23  per  cent,  of  the  officers  of  the  army 
are  graduates  of  the  military  academy.  The  deficiencies 
of  the  West  Point  training  are  further  recognized  by 
officers  of  the  line  in  the  increasing  respect  shown  men 
who  come  up  from  the  ranks  of  civil  life.  The  ap- 
propriations for  West  Point  with  less  than  400  stu- 
dents was  $573,000  in  one  year. 

The  sixty-four  agricultural  colleges  have  received 
from  the  United  States  government  somewhat  more 
than  $106,342,680  as  a  permanent  fund.  They  derived 
from  this  source,  from  State  appropriations  and  other 
sources,  in  1908  an  income  of  more  than  $6,406,982.  It 
is  difficult  to  give  the  number  of  agricultural  students 
accurately  on  account  of  the  fact  that  many  are  en- 
rolled in  several  schools  in  the  universities  with  which 
the  agricultural  schools  are  connected,  but  in  1908, 
6,282  graduated  and  about  26,000  were  enrolled  in  reg- 
ular courses.  This  means  that  agriculture  has  an  en- 
dowment equal  to  $4,000  for  each  student  and  an  in- 
come of  $250  a  year  for  each  student.  The  resources 
of  the  schools  of  engineering,  electrical  engineering, 
forestry  and  other  technical  pursuits  are  so  mixed  in 
their  budgets  with  the  universities  that  their  resources 
are  difficult  to  estimate.  A  single  school  of  technology, 
however,  with  1.500  students,  has  an  endowment  of 
nearly  $2,000,000  and  secures  aid  from  the  State  and 
other  sources  to  a  considerable  amount.  The  total 
income  for  a  year  (1905)  was  a  little  more  than  half 


172  ESSAYS. 

a  million,  and  the  annual  expense  left  a  deficit  of  more 
than  ten  thousand  dollars. 

The  results  of  this  technologic  teaching  are  not  more 
satisfactory  than  are  the  results  of  the  medical  teach- 
ing in  the  best  schools.  The  men  are  not  all  leaders 
in  engineering,  and  few,  indeed,  are  pushing  into  new 
fields.  The  ethical  standards  of  engineering  are  not 
higher  than  business  standards  with  which  engineering 
is  so  intimately  associated.  There  are  high-minded  en- 
gineers wrho  are  as  professional  in  their  work  as  the 
most  conscientious  physician,  but  the  rank  and  file  are 
certainly  below  the  rank  and  file  of  physicians  in  eth- 
ical relations  between  themselves  and  between  them- 
selves and  the  public.  The  prizes  in  engineering  are 
greater  than  in  medicine,  but  the  mediocre  man  has  far 
less  reward  and  a  far  more  insecure  position  than  the 
doctor.  Why  technology  is  so  much  better  endowed 
than  medicine  deserves  further  consideration. 

The  relations  of  the  medical  school  to  the  univer- 
sity is  another  matter  of  extreme  interest.  When  that 
university  is  a  State  university  the  complications  and 
possible  interests  are  multiplied.  The  private  and  tra- 
ditional university  is  essentially  aristocratic,  and,  as 
the  economist  would  say,  capitalistic.  The  endowments 
are  invested  in  mortgages,  in  buildings  and  land,  in, 
stocks  and  bonds  in  various  industries.  The  university 
becomes  a  political  factor  like  any  landlord  or  other  ex- 
ploiter of  labor.  These  interests  cannot  fail  to  show 
themselves  in  the  management  of  a  medical  school  as 
well  as  in  every  other,  department  of  the  university. 
The  freedom  of  the  teacher  may  not  be  obviously  cur- 


HON      173 

tailed,  but  the  general  direction  of  medical  research 
cannot  fail  to  be  modified  by  the  interests  of  a  uni- 
versity corporation  in  tenements,  in  manufacture,  in 
lands  and  in  transportation.  The  projects  of  every  uni- 
versity are  thus  turned,  even  at  the  slightest  angle,  by 
endowments  and  its  particular  methods  of  investment. 

On  the  other  hand,  the  State  university,  when  it 
ceases  aping  the  traditional  university,  will  be  more 
largely  influenced  by  civil  service,  by  the  needs  of  the 
penal  and  custodial  institutions  of  the  State,  by  the  eco- 
nomic interests  of  the  commonwealth  and  by  the  vari- 
ous State  activities.  The  origin  of  the  State  university 
was  distinctly  democratic.  It  was  designed  to  be  the 
dome  of  popular  public  education.  In  each  State  it 
has  developed  with  certain  local  modification  under  the 
general  traditional  scholastic  public  opinion  of  the  pro- 
fessional presidents  and  professional  professors.  Now 
it  is  difficult  to  see  the  difference  between  the  better 
State  universities  and  the  older  endowed  universities, 
and,  moreover,  professors  pass  without  losing  much 
caste  from  the  latter  to  the  former.  If  we  make  a  dif- 
ferential diagnosis  between  the  spirit  of  the  traditional 
and  the  spirit  of  the  State  university  we  shall  find 
that  the  former  is  scholastic,  pedantic,  conventional, 
complacent,  timid  and  critical.  The  latter  is  demo- 
cratic, utilitarian,  venturesome,  ambitious.  The  for- 
mer has  the  poise  of  age,  the  latter  the  exuberance  of 
youth.  The  former  is  cosmopolitan,  the  latter  pro- 
vincial. 

It  is  extremely  unfortunate  that  many  of  our  State 
universities  follow  too  closely  the  fashions  of  the  pri- 


174  £55 

vate  foundations.  Thus  they  become  imitative,  inane 
and  ridiculous.  The  State  university  should  be  the 
conscience  of  the  State,  an  intellectual  court  of  last 
resort,  an  automatic  source  of  corrective  prescience,  of 
legal  prescience,  of  judicial  prescience,  of  economic 
prescience,  of  sanitary  prescience  and  of  social  pre- 
science. The  hope  of  the  permanency  of  our  present 
civilization  rests  in  the  adoption  of  rational  modifica- 
tions of  our  laws,  our  conventions  and  our  social  re- 
lations. Through  our  great  conquest  of  nature  our 
material  resources  are  almost  unbounded.  \Yith  the 
meager  assistance  of  medicine  the  death-rate  of  the 
first  five  years  of  life  has  been  reduced  to  a  tithe. 
Many  dread  epidemics  have  been  robbed  of  their  hor- 
ror.-. The  hospitals  of  the  world  have  been  multiplied 
a  hundred- fold  in  their  effectiveness.  Even  war  is 
robbed  of  half  its  terrors,  and  more  than  half  its  de- 
structiveness  by  sanitary  and  surgical  science.  The 
greater  and  the  more  constant  danger  of  society  from 
the  delinquent,  the  defective  and  the  dependent  classes 
is  so  complicated  and  imminent  a  problem  that  it  re- 
quires all  the  wisdom  of  all  the  faculties  to  find  a  way 
out.  That  this  problem  will  be  solved  no  one  who 
appreciates  the  fertility  of  the  human  mind  can  doubt. 
Much  of  the  research  must  be  done  in  the  medical  lab- 
oratories and  all  of  it  under  the  guidance  of  thoroughly 
practical  clinical  men.  An  idea1!  medical  school  would 
be  an  ideal  place  for  the  State  to  work  out  the  prob- 
lem of  self-preservation.  The  nation  supports  its  war 
college;  the  State  should  as  liberally  support  its  col- 


U'HO  PAYS  FOR  MEDICAL  EDUCATION       175 

lege  of  peace.  The  nation  supports  a  magnificent  navy ; 
the  State  should  support  with  equal  prodigality  the 
laboratories  for  saving  life  and  preventing  suffering. 


PRACTICAL  HYGIENE  IN  THE  MEDICAL 
SCHOOL. 


THE  morbidity  of  medical  students  is  proverbially  ex- 
cessive. Out  of  every  graduating  class  of  one  hundred 
there  are  two  or  more  graduated  in  absentia  on  account 
of  active  tuberculosis. 

So  far  as  the  writer's  knowledge  extends,  no  medi- 
cal school  in  the  United  States  has  any  physical  exam- 
ination on  admission,  and  no  medical  care  of  its  stu- 
dents during  the  course  of  study.  The  amphitheatres, 
laboratories  and  classrooms  are  far  from  models  of 
sanitary  construction,  and  the  janitor  service  and  con- 
ditions of  existence  do  not  savor  of  care  for  the  health 
of  the  students.  A  glance  at  the  schedule  of  lectures 
shows  that  an  inordinate  amount  of  time  must  be  put 
in  by  the  student  in  the  over-heated,  dusty,  nasty,  lec- 
ture-rooms and  in  surroundings  which  would  be  dan- 
gerous enough  if  the  students  were  exposed  to  them 
only  a  few  hours  a  day. 

The  students  themselves  are  at  a  critical  period  of 
life.  They  range  between  nineteen  and  twenty-six. 
The  po\vers  of  nature  make  over- work  easy,  and  ambi- 
tion and  passion  rule  as  at  no  other  period  of  life.  The 
traditions  of  the  medical  school  are  in  the  direction  of 
non-conventional  conduct  and  freedom  from  all  re- 
straints. As  a  rule,  medical  students  drink  too  much, 
smoke  too  much,  and  are  too  free  with  women.  They 
do  not  eat  enough,  sleep  enough,  nor  have  enough  rec- 
reation in  the  fresh  air.  They  befoul  the  lecture-rooms 

1  —  T 
I// 


and  amphitheatres  with  tobacco  smoke  and  expecto- 
ration. They  sleep  in  close,  over-heated  rooms  and 
read  unseasonable  hours  with  poor  or  badly  arranged 
lights.  So  far  as  our  experience  goes,  no  student  group 
has  ever  made  any  systematic  effort  to  improve  the  san- 
itary conditions  of  the  whole  student  body.  The  anti- 
tobacco  and  anti-alcohol  crusades  of  the  Y.  M.  C.  A. 
groups  have  not  had  such  a  foundation  as  to  command 
the  confidence  of  the  student  body. 

The  medical  faculty  is  growing  from  year  to  year 
more  and  more  out  of  sympathy  and  touch  with  the  stu- 
dent body.  The  management  of  the  medical  school  is 
confronted  with  the  enormous  growing  expense  of  the 
modern  medical  school  and  the  terrible  competition 
which  exists  betwen  rival  institutions.  The  difficul- 
ties of  meeting  the  requirements  of  the  State  examin- 
ing boards  and  the  constant  advances  in  the  frontier 
of  the  science  of  medical  practice  take  up  the  energies 
of  the  management,  and  they  have  no  time  to  consider 
the  health  of  the  student  body  or  the  sanitation  of  their 
classrooms.  In  a  few  institutions,  where  new  buildings 
have  been  constructed,  better  and  more  appropriate 
conditions  are  attained,  but  for  the  most  part  this  is  a 
passive  improvement  rather  than  an  active  betterment. 
The  heart  of  the  medical  faculty  is  not  in  the  health 
of  the  medical  student  body. 

Every  medical  school  has  a  course  in  hygiene.  Theo- 
retical health  is  discussed  under  conditions  ideally  path- 
ogenic. Warming,  ventilating,  lighting  and  hous-e- 
cleaning  are  presented  by  the  pedagogic  method  of  "the 
horrible  example.''  The  janitors  of  the  medical  school, 


HYCIEN,  EDICAL  SCHOOL.  179 

like  the  janitors  of  our  public  schools,  seem  to  be  se- 
lected because  they  are  already  tuberculous  or  have  all 
the  habits  which  make  them  early  succumb  to  the  dis- 
ease. 

It  stands  without  saying  that  the  medical  school 
should  be  ideal  in  all  matters  of  health  and  sanitation. 
Better  a  sanitary,  medical  school  than  twenty  courses  in 
sanitation  in  all  the  unmentionably  nasty  medical  school 
buildings  in  the  country.  Better  that  the  15,000  med- 
ical students  of  the  United  States  be  trained  for  four 
years  in  personal  hygiene  and  right  habits  of  life  th?n 
that  they  pass  two  majors  in  the  theory  of  health. 

The  young  medical  man  gets  a  rather  cool  reception 
when  he  goes  out  to  do  on  the  people  all  the  brilliant 
things  which  he  sees  accentuated  during  his  four-year 
course.  The  people  don't  want  to  be  laparotomized 
or  have  their  ribs  taken  out.  They  object  to  having 
their  antrums  opened  or  their  mastoids  chiseled  off, 
however  clear  the  indications  may  be  to  the  mind  of 
the  young  doctor.  If.  however,  he  had  been  active 
in  trying  to  make  the  public  school  house  clean  and 
airy,  in  order  to  prevent  all  the  colds,  adenoids  and 
bronchitises  which  so  often  end  in  serious  conditions 
calling  for  surgery,  he  may  possibly  get  some  rec«  igni- 
tion. The  young  doctor  must  go  forth  to  counsel 
the  people  who  become  his  patients  in  all  the  manners 
of  life  by  which  disease  may  be  forestalled.  That  they 
are  not  ready  to  pay  the  young  doctor  for  the  great 
operation,  has  been  demonstrated  ad  libitum.  That  they 
will  pay  for  the  foresight  of  the  wise  young  doctor 
awaits  future  demonstration. 


THE  MEDICAL  ORGANIZATION  OF  THE  FU- 
TURE AND  "THE  GOOD  DOCTOR." 


Ix  not  a  very  remote  time  and  in  a  not  very  distant 
city  a  physician  was  once  taken  sick.  One  of  his  col- 
leagues was  called  to  care  for  him,  and  all  his  other 
colleagues  were  detailed  from  day  to  day  to  care  for 
the  patient's  patients  and  keep  his  office  hours.  In  time 
the  sick  doctor  made  such  recovery  that  he  was  sent 
to  Europe  for  complete  convalescence,  and  his  col- 
leagues stayed  at  home  and  made  regular  remittances 
from  his  practice,  which  they  maintained  in  its  integ- 
rity by -a  sort  of  a  relay  method,  for  us  of  1909  hard 
to  understand.  At  the  end  of  his  convalescence  he 
came  back  to  his  intact  practice.  His  office  was  as  full 
as  ever.  His  former  patients  were  his  still  and  his 
finances  had  not  suffered  more  from  his  sickness  than 
those  of  a  sick  merchant  or  banker.  The  integrity  of 
the  medical  profession  in  that  city  as  well  as  the  integ- 
rity of  the  sick  doctor's  practice  was  preserved. 

At  a  recent  meeting  of  a  State  medical  society,  the 
question  of  medical  defense  was  discussed.  The  so- 
ciety, at  length,  by  its  star  chamber,  was  committed 
to  this  adventure.  This  State  society  publishes  a 
monthly  journal,  though  it  is  too  poor  to  provide 
stenographers  to  report  discussions  of  the  papers  read. 
It  now  undertakes  to  defend  every  member  of  the  State 
society  in  every  malpractice  suit.  Whether  innocent 
or  guilty,  whether  capable  or  incompetent,  whether 
equipped  or  deficient,  he  is  to  have  well-paid  advo- 

181 


cates.  It  certainly  will  make  this  State  society  attrac- 
tive to  the  scum  of  the  medical  practitioners  who  have 
never  before  seen  reason  to  put  up  the  fee  for  mem- 
bership. It  will  certainly  bring  out  some  of  the  stay- 
at-homes. 

The  two  preceding  incidents  characterize  the  spirit, 
the  former  of  a  professional  society  and  the  latter  of  a 
trades  union.  Any  careful  observer  must  recognize  the. 
trend  of  our  medical  organization,  the  disintegration 
of  the  professional  spirit  which  has  earned  medicine 
the  respect  of  the  world  and  given  the  doctor  a  social 
position  among  gentlemen,  and  the  incarnation  of  the 
trades  union  spirit  which  breeds  strife,  strikes  and  the 
ethics  of  the  walking  delegate  and  the  picket. 

The  trend  of  the  organization  is  soulless  and  iron- 
clad. Papers  must  be  read  inside  of  fifteen  minutes, 
and  discussions  must  be  limited  to  five  minutes.  Pa- 
pers must  pass  a  publishing  committee,  and  be  pub- 
lished in  the  official  journal.  The  society  has  a  com- 
mittee on  political  action,  and  there  is  no  reason  to 
think  this  committee  would  object  to  funds  for  pub- 
licity and  corruption.  "The  fact  is,  the  medical  soci- 
ety," as  one  of  its  members  said  on  the  floor,  "is  letting 
ethics  and  hygiene  rest  while  it  tries  out  business 
methods  in  medicine." 

This  remark  made  me  recall  what  little  remained  in 
my  gray  matter  of  business  methods  learned  during  the 
last  twenty  years.  My  knowledge  of  business  is  natur- 
ally very  limited  in  detail,  but  very  extensive  in  gen- 
eral. It  has  settled  down  in  my  Euclid  of  Ethics  that 
"all  business  is  bad,  and  that  the  most  successful  is  the 


"THE  GOOD  DOCTOR."  183 

worst."  Now,  this  doctor  would  apply  business  meth- 
ods to  medicine.  He  would  "land"  as  many  operations 
as  possible  and  soak  every  one  for  the  biggest  fee.  His 
motto  would  be,  "From  every  one  according  to  his 
necessity." 

I  suppose  this  federation  of  business-like  doctors  has 
come  to  stay,  and  that  we  must  make  the  most  of 
their  bumptious  methods.  We  must  read  their  jour- 
nals, pay  their  lawyers,  collect  our  bills  through  their 
collecting  agencies,  insure  our  automobiles  in  their 
companies,  get  our  instruments  of  their  instrument 
houses,  refer  our  patients  to  their  accredited  druggists, 
contribute  our  mites  to  their  old-age  fund  and  patron- 
ize at  last  their  official  undertakers.  Otherwise  we  will 
be  called  scabs  and  be  treated  like  scabs. 

There  is  every  reason  why  the  medical  profession 
should  co-operate  in  maintaining  a  medical  library, 
such  as  that  of  the  Academy  of  Medicine  in  New  York. 
There  is  good  reason  why  the  medical  profession 
should  erect  and  maintain  such  a  memorial  mansion  as 
the  Langenbeck  House  in  Berlin.  It  may  be  that  to  a 
clearer  reason  than  mine  there  is  equal  argument  for  a 
physicians'  publishing  house,  an  official  malpractice  de- 
fense league,  a  physicians'  instrument  and  drug  mail 
order  store,  a  physicians'  laundry,  and  so  on  to  the 
end. 

In  this  mechanical  and  business-like  exploitation  of 
our  group,  where  has  that  tradition  "the  good  doctor'' 
a  place?  The  answer  has  not  yet  been  given  out  offi- 
cially, and  its  publication  here  would  be  premature, 
but  it  may  be  safely  said  ,  as  it  has  been  said  so  often 
before,  that  "a  sucker  is  born  every  minute." 


THE  INFLUENCE  OF  THE  AMERICAN  MEDI- 
CAL ASSOCIATION  AS  NOW  ORGANIZED 
UPON  CURRENT  MEDICAL  LITERATURE. 


THE  merest  glance  at  the  constitution  and  by-laws  of 
the  American  Medical  Association  will  convince  any 
one  of  the  undemocratic,  though  apparently  representa- 
tive, form  of  government  that  it  secures.  There  is  no 
place  where  the  star  chamber  can  be  checked  or  the 
great  mass  of  busy  professional  men  who  make  up 
the  body  of  the  organization  can  be  heard  from.  The 
officers  are  nominated  and  elected  without  any  refer- 
ence to  the  bulk  of  the  52,000  members  of  the  asso- 
ciation who  are  not  present  at  the  place  and  hour.  The 
constitution  of  the  association  is  hard  and  slow  to 
change.  The  unrestrained  powers  which  it  gives  its 
officers  are  numerous  for  good  or  evil.  This  consti- 
tution resembles  that  of  a  great  political  party.  It  is 
devoid  of  all  those  features  which  the  thought  and 
experience  of  the  world  since  the  French  Revolution 
have  made  almost  axiomatic.  The  initiative  and  ref- 
erendum, or  direct  legislation,  are  unprovided  for,  and 
there  is  no  real  election  of  officers — they  are  simply  ac- 
claimed. \Yith  an  educated  body  like  our  profession, 
preferential  voting  would  be  not  only  easy  but  effective 
in  expressing  the  will  of  the  mass,  if  such  an  expres- 
sion was  desired  by  the  organization. 

Perhaps  the  rank  and  file  of  the  profession  would 
not  care  what  sort  of  an  organization  managed  the 
meetings  were  it  not  for  the  unpremeditated  departure 

135 


186  ESSAYS. 

of  the  organization  into  the  publishing  business.  It 
matters  little  who  reads  a  paper  on  colic,  but  it  does 
matter  if  one  cannot  find  a  place  to  publish  such  a 
paper.  Originally  the  proceedings  of  the  association 
appeared  in  an  annual  volume.  The  postal  laws  im- 
posed a  heavy  tax  (eight  dollars  per  hundredweight) 
on  the  transmission  of  books  of  that  kind  through  the 
mails.  The  same  end,  the  publication  of  the  papers 
and  proceedings,  could  be  attained  and  the  mails  would 
carry  them  for  one  dollar  per  hundredweight.  The 
most  common  sense  dictated  the  establishment  of  a 
weekly  journal  to  circumvent  the  postal  rules  and  the 
express  charges,  and  in  1883  the  Journal  of  the  Ameri- 
can Medical  Association  was  established.  If  the  phar- 
maceutical houses  taxed  us  as  the  express  companies 
and  the  mails  did  twenty-five  years  ago,  and  there  was 
no  other  recourse,  the  same  common  sense  would  dic- 
tate the  establishment  of  the  pharmacy  of  the  Ameri- 
can Medical  Association. 

The  establishment  of  its  Journal  was  coincident  with 
the  rapid  growth  of  the  organization,  and  was  a  mo- 
tive for  and  an  engine  in  that  extension.  The  Journal 
in  the  early  years  had  great  profit  from  advertisements, 
and  soon  added  to  the  resources  of  the  association, 
both  in  influence  and  in  financial  resource.  It  soon 
became  a  honey-pot  to  the  medico-political  diptera, 
and  as  the  trustees  now  had  financial  plums  to  bestow, 
the  "ancient  and  honorable"  were  displaced  by  the 
busy  and  aggressive.  The  Journal  was  managed  on 
business  principles.  The  circulation  grew  with  the  or- 
ganization of  the  profession.  The  State  and  (local) 


CURRENT  MEDICAL  LITERATURE.  187 

county  societies  were  hitched  on  behind  the  associa- 
tion, and  star  chambers,  when  they  did  not  already 
exist  in  these  organizations,  were  instituted  to  train 
into  the  star  chamber  of  the  national  association.  The 
State  journals  were  encouraged  and  bureaucracy  en- 
trenched. Now  that  the  position  of  the  clique  (or,  as 
one  of  their  number  explained  to  me,  the  "good  fel- 
lows who  would  turn  out  and  give  and  take")  was  es- 
tablished, rivals  must  be  eliminated.  The  private  jour- 
nals depended  on  circulation  and  advertisements.  If 
either  of  these  could  be  curtailed  it  would  cripple  the 
rival.  Immediately  an  Index  expurgatus  of  advertis- 
ers was  promulgated,  and  every  medical  organization, 
through  its  house  of  delegates,  council  or  otherwise- 
named  star  chamber,  was  directed  to  see  to  the  pun- 
ishment of  offenders.  And  this  righteous  diversion  is 
still  going  on. 

Current  medical  literature  divides  itself  logically 
and  naturally  by  its  contents  into  general  medical  lit- 
erature, on  the  one  hand,  which  appeals  to  and  is  read 
by  the  general  practitioner  and  all  other  medical  men 
alike,  and  the  literature  of  the  specialist,  which  con- 
cerns these  branches  of  medicine  and  is  intelligible 
only  to  the  single  class  for  which  it  was  written.  Origi- 
nally all  medical  journals  belonged  to  the  former  group, 
but  of  late  (twenty-five  to  thirty  years)  the  latter 
group  has  developed  enormously,  and,  in  a  measure, 
at  the  expense  of  general  medical  literature.  This  con- 
dition prevails  in  the  several  countries  of  Europe  as 
in  America  and  the  Orient. 

Again,  the  general  medical  literature  divides  itself 


ESSAYS. 

into  the  local  and  the  cosmopolitan.  The  local  jour- 
nals are  generally  of  infrequent  issue,  while  the  gen- 
eral cosmopolitan  medical  publications  almost  always 
appear  once  a  week. 

Th(e  scientific  and  professional  value  and  bulk  of  this 
literature  varies  for  the  several  countries  with  the  re- 
muneration, education,  customs,  history  and  habits  of 
the  national  profession.  In  England,  where  the  doc- 
tors are  poorly  paid  and  ranked  socially  just  below  ten- 
ant farmers  and  above  established  butchers,  general 
medical  literature  is  represented  by  two  bulky  and 
chaffy  journals — the  Lancet,  privately  owned  (circula- 
tion 10,000)  and  the  British  Medical  Journal,  a  society 
venture  (22,000).  No  other  European  nation  makes  a 
worse  showing  in  general  medical  literature,  unless  it 
is  the  French,  with  their  many  little  weeklies.  Ger- 
many, or  rather  the  German-reading  profession  on 
the  continent  has  seven  great  medical  weeklies,  pri- 
rately  owned — the  Berliner,  Deutsche,  Mitnchener  and 
Prager  incdiz'niische  IVochenschrift,  Correspondent 
blatt  filr  Schweitzer  Aerzie,  the  Medizlv.ischc  Klinik 
and  the  Wiener  klinische  Wochenshrift.  These  jour- 
nals maintain  the  highest  scientifie  and  literary  stand- 
ards. No  better  articles,  articles  from  no  better  men, 
articles  in  no  better  form,  are  published  in  the  more 
ponderous  and  elaborate  Beiarage  than  in  these  week- 
lies. The  scientific  value  of  this  literature  unques- 
tionably outranks  that  of  the  English,  French  or  Amer- 
ican journals  of  general  medical  literature. 

Next  to  the  literature  of  German-reading  Europe 
stands  without  question  the  literature  of  America  as 


CURRENT  MEDICAL  LITERATURE.  189 

represented  in  the  five  great  medical  weeklies  —  the 
Journal  of  the  American  Medical  Association,  a  society 
organ  (circulation  52,000),  and  the  four  privately 
owned  journals,  the  Boston  Medical  and  Surgical  Jour- 
nal (circulation  6,000),  the  Medical  Record  (circula- 
tion 10,000),  the  New  York  Medical  Journal  (circula- 
tion 22,000),  and  the  Lancet-Clinic  (circulation  5,000). 
Like  their  German  compeers,  these  weeklies  have  an 
individuality  of  their  own.  The  Journal  of  the  Amer- 
ican Medical  Association  puts  out  about  one  hundred 
pages  of  reading  matter  and  half  as  much  advertising, 
while  the  other  weeklies  give  less  than  fifty  pages  of 
reading  matter  and  a  little  more  or  a  little  less  adver- 
tising. 

But  it  is  in  the  quality  of  the  original  articles  that 
we  are  interested.  If  in  these  pages  we  may  express 
an  opinion  in  which  the  Lancet-Clinic  shall  not  be  con- 
sidered, the  four  remaining  weeklies  are  neck  and  neck 
in  the  quantity  of  valuable  matter.  The  Boston  Medi- 
cal and  Surgical  Journal  and  the  two  New  York  jour- 
nals publish  fewer  pages  of  what  might  be  termed 
skultch.  In  editorial  matter  the  New  York  Medical 
Journal  leads,  with  the  Medical  Record  second.  The 
so-called  editorials  of  the  Journal  of  the  American 
Medical  Association  are  for  the  most  part  abstracts  of 
literature  of  more  or  less  timely  interest.  They  are 
impersonal  and  often  stale.  They  never  give  offense 
or  arouse  discussion.  The  abstracts,  correspondence 
and  medical  news  in  these  great  weeklies  differ  in  quan- 
tity and  quality,  but  in  no  one  journal  is  there  any 
great  superiority,  except  in  quantity.  The  association 


190  ESSAYS. 

journal  leads  in  that  in  every  department.  Book  re- 
views are  unknown  in  any  of  our  medical  weeklies. 
It  is  possible  the  book  review  is  gone  to  stay.  It  is 
possible  in  these  days  of  card  catalogues  and  special 
journals  that  the  medical  book  worthy  a  review  is 
also  a  memory.  The  great  men  who  know  how  to  do 
things  are  to  busy  to  write  books  or  read  them. 

We  are  interested  in  the  future  of  cosmopolitan  (non- 
local) general  medical  journals.  Are  we  to  have  one 
American  medical  journal,  just  as  we  have  one  Con- 
gressional Record?  Are  we  to  have  two,  as  our 
English  neighbors  do,  one  officinal  and  the  other  a 
private  enterprise? 

The  active  medical  enterprise  of  German-speaking 
Europe  uses  more  than  seven  weekly  medical  newspa- 
pers of  the  first  rank.  Hardly  one  of  these  would  be 
embarrassed  by  a  strict  comparison  with  our  best. 
The  university  and  the  open  hospital  furnish  material 
for  these  five  weeklies,  while  the  library-trained  med- 
ical profession  demands  the  clinical  and  scientific 
weekly. 

The  medical  profession  of  the  United  States  is  be- 
ing thoroughly  unionized  by  the  efforts  of  the  Ameri- 
can Medical  Association.  The  process  is  inevitable, 
though  in  some  of  its  aspects  unprofessional  and  la- 
mentable. 

The  new  Harvard  Medical  School  needs  a  Boston 
Medical  and  Surgical  Journal  for  effective  expression 
of  its  spirit  and  adventure;  Columbia,  Philadelphia, 
Johns  Hopkins  need  the  Medical  Record  and  the  New 
York  Medical  Journal.  The  new  school  in  Cincinnati 


CURREXT  MEDICAL  LITERATURE.  191 

must  have  as  good.  Can  the  universities  and  the  pro- 
fession allow  the  complete  extinction  of  all  private 
weeklies?  If  some  active  steps  are  not  soon  taken 
we  shall  find  ourselves  so  completely  organized  that 
we  shall  have  no  means  of  expression  or  redress. 


THE  MEDICAL  BOOK  STORE. 


THE  great .  influence  of  the  book  store  on  literature 
and  library  culture  is  proverbial.  Not  to  mention  more 
classic  examples,  the  corner  book  store  in  Boston 
was  the  geopgraphic  center  of  the  greatest  intellec- 
tual and  literary  awakening  of  our  Atlantic  seaboard, 
and  the  "Amen  Corner"  in  S.  C.  Griggs'  Book  Store 
was  the  center  of  literary  life  in  Chicago. 

In  medicine,  the  influence  of  the  book  store  in  Phil- 
adelphia made  a  medical  publishing  center  there,  and 
also  attracted  to  that  city  medical  students  and  pa- 
tients seeking  medical  aid.  A  long  list  of  names  is 
associated  with  the  development  of  medicine  in  the 
Quaker  City,  out  of  which  have  come  forth  a  num- 
ber of  such  brilliant  contributors  to  belles  lettres  that 
they  are  almost  forgotten  as  physicians.  Now  the 
medical  book  store  in  Philadelphia  is  a  memory.  The 
metropolitan  cities  even  have  no  medical  book  stores. 
Medical  books  are  kept  in  back  rooms  in  some  of  our 
general  book  stores,  but  the  absence  of  a  real  medical 
book  store  is  a  conspicuous  sign  of  the  evolution  or 
devolution  of  medicine. 

We  have  called  attention  elsewhere  to  the  rapid  ex- 
tinction of  the  weekly  medical  journal,  and  we  attrib- 
uted it  in  a  great  measure  to  the  unwise,  if  not  unfair, 
activities  of  the  American  Medical  Association  through 
its  journal.  The  whole  fabric  of  medical  literature 
has  changed  much,  and  the  book  trade  most  of  all. 
The  publishers  now  find  it  pays  to  put  out  hundreds 

193 


194  ESSAYS. 

of  canvassers  who  sell  by  prospectus  and  subscription 
only.  The  books  are  heavy,  big  and  pictorial.  They 
are  often  in  so-called  "libraries"  or  series  of  six  to 
sixty  volumes,  and  average  about  six  dollars  a  vol- 
ume. The  doctor  pays  by  the  month  to  a  collector 
who  visits  him  at  definite  pre-arranged  times.  Many  of 
our  best  books  can  be  obtained  in  no  other  way,  and 
they  are  used  to  foist  more  showy  or  sensational  books 
on  the  market.  We  must  not  complain  if  the  pub- 
lishers can  circulate  good  books  in  no  other  way,  but 
this  is  one  of  the  functions  which  has  dealt  a  vital 
blow  to  the  medical  book  store. 

Another  factor  which  must  be  considered  is  the 
fallacious  nation  prevalent  among  physicians  'that 
only  recent  books  on  medicine  are  valuable,  and  that 
all  recent  books  are  filled  with  novelties  that  are 
useful.  Many  of  the  best  medical  books  are  twenty 
years  old,  and  a  few  that  every  student  and  physi- 
cian should  read  are  older  still.  The  great  mass  of 
material  to  be  found  in  the  library  of  a  prosperous 
physician  who  has  freely  attached  his  name  to  sub- 
scription blanks  is  trash  of  the  most  useless  and  worth- 
less sort.  Still,  the  delusion  prevails  that  new  books 
are  good  books  to  buy.  Big  books  and  picture  books 
sell  by  subscription. 

There  is  reason  to  believe  that  medical  books  are 
not  read  by  physicians  as  much  as  they  should  be. 
They  are  referred  to  and  kept  on  exhibition,  but  they 
are  too  heavy  to  be  perused  in  these  hustling  times. 
The  physician  has  to  be  up  and  doing  in  order  to 
get  into  the  band  wagon,  and  even  the  band  wagon, 


THE   MEDICAL   BOOK   STORE.  195 

when  he  gets  there,  does  not  prove  to  be  a  very  good 
place  for  reading  or  writing. 

What  can  be  done  about  it?  Well,  nothing.  But 
let  us  at  least  see  how  things  are,  and  where,  as  a  pro- 
fession we  are  going.  We  are  becoming  thoroughly 
unionized  in  our  organization  and  are  becoming  trades 
unionized  in  our  practice.  We  are  not  in  the  practice 
of  medicine  for  our  health,  and  if  we  read  the  signs 
aright  the  people  are  getting  onto  it.  They  even  hint 
that  we  are  not  always  in  it  for  their  health,  and  that 
is  what  they  are  paying  us  for.  We  have  traded 
pretty  successfully — some  of  us  have —  on  the  profes- 
sional reputation  established  for  us  by  our  predeces- 
sors. We  still  wear  the  regalia  of  /Esculapius,  but 
do  not  always  follow  the  ethics  of  Hippocrates,  Galen, 
Sydenham  and  Davis. 


THE  ADVANTAGES  OF  TEAM  WORK  IN 
MEDICAL  RESEARCH. 


THE  days  of  individualism  are  over  in  almost  every 
department  of  life.  The  very  essence  of  our  mastery 
over  ignorance  and  the  powers  of  nature  depend  on 
large  composite  units.  It  takes  a  better  and  more 
considerate  man  to  be  one  of  a  team  that  it  does  to 
work  or  fight  alone. 

The  prophet  and  the  artist  can  hardly  exist  except 
in  stimulating  surroundings,  though  their  actual  pro- 
ductions are  the  labor  of  solitude.  The  voluntary  or- 
ganization of  medical  men  produces  societies,  but  not 
often  teams  fighting  on  the  boundary  of  science. 

It  is  very  difficult  to  do  one's  best  every  time;  the 
artist,  the  poet  and  the  genius  often  fail  of  the  high- 
est mark  of  excellence.  Society  is  not  always  at  its 
best.  There  are  long  periods  when  it  is  on  the  plateau 
of  sordid  drudgery.  Then  there  is  a  sudden  rise  to 
a  plane  of  broader  vision  and  clearer  conception  and 
achievement. 

Medical  societies  are  no  exception  to  this  law  of 
protracted  mediocrity  and  short  but  sudden  ascent  to  a 
plateau  of  unusual  brilliancy. 

For  a  long  time  our  medical  societies  have  been 
dreary  and  Sterile.  In  spite  of  seeking  after  strange 
and  false  idols,  little  grain  has  come  from  a  great 
mass  of  chaff. 

The  meeting  of  the  Chicago  Neurological  Society, 
January  27,  was  an  ideal  in  form,  conduct  and  mat- 

197 


198  ESSAYS. 

ter.  It  was  held  in  a  noisy  hostlery,  the  medical  pro- 
fession of  Chicago  being  still  houseless  and  homeless. 
This  meeting  furnishes  an  immediate  model  for  fu- 
ture efforts  of  the  scientific  faculty  of  every  commu- 
nity. The  evening  was  devoted  almost  exclusively 
to  the  subject  of  hypophyseal  disease,  which  was  pre- 
sented from  the  three  points  of  view  by  the  neuro- 
logical, the  ophthalmological  and  surgical  members 
in  a  most  scientific,  concise,  clear  and  masterly  man 
ner.  Dr.  A.  Kanavel  described  his  method  of  hypo- 
physectomy  by  approaching  the  sella  turcica  through 
the  sphenoidal  sinus,  first  making  an  incision  under 
the  nose  and  around  the  alse  to  the  prominence  of  the 
malar,  then  cutting  through  the  septum  to  the  poste- 
rior nares  above  the  middle  turbinates,  and  raising  the 
nose  upward  onto  the  forehead  by  breaking  the  root  of 
the  nose  and  using  it  as  a  hinge.  The  upper  turbinate 
and  the  larger  part  of  the  ethmoid  were  removed,  the 
j>phenoid  opened  and  its  septum  removed,  ancl  the 
base  of  the  cella  turcica  cut  away.  The  tun'or  is 
then  removed  with  a  sharp  spoon.  The  anesthetic 
i?  rectal  etherization,  and  the  blood  is  kept  out  of 
the  air  passages  by  a  tamponade  of  the  posterior 
nares  as  for  nose  bleed.  KanaveFs  careful  work  on 
the  cadaver,  and  anatomic  and  pathological  studies, 
well  prepared  him  for  the  dramatic  removal  of  a  well- 
diagnosed  tumor  of  the  pituitary  body.  The  patient 
did  well  for  six  weeks,  but  died  of  the  progress  of 
the  malignant  disease,  for  which  the  operation  was 
unavailing. 

Dr.  H.  E.  Halstead  showed  a  patient  from  whom 


TEAM  WORK  IN  MEDICAL  RESEARCH          199 

he  had  removed  the  hypophyseal  tumor  which  had 
produced  blindness  and  a  comatose  condition  lasting 
several  weeks.  The  method  of  Kanavel  was  not  fol- 
lowed exactly,  but  the  upper  lip  was  turned  up  and 
an  incision  into  the  nose  made  by  stripping  the  lip 
away  from  the  superior  maxilla  as  high  as  the  orbits, 
and  otherwise  following  KanaveFs  technique.  Tren- 
delenburg  tracheotomy  tube  and  ether  was  used  for  an 
anesthetic.  The  patient,  scarless  iand  restored  *to 
sight,  and  in  a  normal,  useful  condition,  showed 
himself. 

Dr.  Halstead  reported  a  second  operation  in  a  des- 
perate case,  upon  a  woman  who  died  shortly  after 
the  operation.  The  plans,  specifications,  radiographs 
and  technical  appliances  used  ,in,  these  operations 
were  presented,  as  well  as  the  history,  neurological 
findings,  ophthamological  findings,  and  all  the  de- 
ductions and  indications  therefrom  were  presented 
by  men  in  whose  services  these  patients  presented 
themselves.  Dr.  Dean  Lewis  gave  a  concise  and 
classical  description  of  the  specimens  removed,  with 
a  masterly  summary  of  our  knowledge  of  the  embry- 
ologic  origin  of  these  tumors. 

Dr.  D'Orsay  Hecht  presented  a  young  woman  with 
hypophyseal  disease,  in  the  diagnosis  of  which  he  had 
used  all  the  resources  of  our  science.  Especially  in- 
teresting were  the  studies  of  metabolism  made  in  the 
case  of  Prof.  Mathews,  of  the  University  of  Chicago, 
and  the  deductions  which  the  results  of  the  studies 
warranted. 

The    discussion    by   members    of   the   society    and 


200  ESSAYS. 

guests  was  pertinent,  active  and  well  taken.  The  ad- 
journment was  made  after  the  contributors  to  the 
seminar  had  been  duly  commended  by  a  flattering 
resolution. 

This  work  could  not  have  been  accomplished  ex- 
cept by  the  united  yet  wholly  independent  work  of 
the  men  concerned.  Each  one,  a  master  in  his  own 
sphere,  helped  on  the  achievement  of  a  distinct  ad- 
vance in  the  surgery  of  the  base  of  the  brain  and  in 
the  conquest  of  a  mastery  over  the  internal  or  auto- 
genous toxemias. 


ORPHANOTROPHISM. 


To  those  of  us  who  really  want  things  done  by  soci- 
ety, she  seems  obstinately  slow.  This  slowness  is 
apparent  rather  than  real.  When  she  really  gets  ago- 
ing she  makes  this  old  world  hum.  When  Socrates 
was  a  boy,  Athens  was  a  village  of  thatched  houses 
almost  hovels;  when  he  drank  the  fatal  hemlock,  it 
was  a  city  of  marble  palaces  and  temples  adorned  with 
the  sculpture  of  Phideas.  An  equally  great  intellec- 
tual revolution  had  gone  on  with  this  material  and 
artistic  advance.  As  remarkable  examples  of  great 
world  movements  might  be  cited,  those  occurring  dur- 
ing the  life  of  Columbus,  that  of  our  own  fathers 
and  even  in  the  short  span  of  our  own  unfinished 
lives. 

History  has  not  always  set  down  the  unconscious 
acts  of  society.  The  spirit  of  the  time,  the  Zeitgeist 
and  the  IVeltgeist,  are  so  encompassing  and  engross- 
ing that  no  historian  has  the  perspective  to  conceive 
and  narrate  the  doings  and  achievements  of  his  time. 
Many  of  the  social  advancements  in  which  we  are 
interested  to-day  were  brought  about  unconsciously, 
many  so  remotely  that  all  the  records  of  the  events 
are  lost. 

If  we  attempt  to  meander  the  uncertain  course  of 
human  progress  in  culture,  civilization  and  self-mas- 
tery, no  evidence  will  be  found  more  profoundly 
suggestive  of  the  deeper  psychical  conditions  of  each 
succeeding  age  or  more  curiously  conclusive  of  the 

201 


202  ESSAYS. 

complete  moulting  of  the  old  ideal  and  the  adop- 
tion of  the  new,  than  the  linguistic  driftwood  found 
in  obsolete  and  abandoned  words  cast  away  by  the 
languages  because  of  unpleasant  associations.  The 
psychiatrist  would  find  the  skeleton  in  the  closet  of 
the  deluded  mind  by  noting  the  words  which  the 
patient  shies  at;  so  civilization  shies  at  words  that 
spell  disgrace  to  a  preceding  era. 

It  stands  to  reason  that  with  new  ideas  and  asso- 
ciations new  words  are  adopted  and  coined  into  the 
vernacular.  As  the  murderous  and  pastoral  barba- 
rian became  a  settled  tree-growing  agriculturist,  pri- 
vate property  and  the  exclusive  family  arose,  and 
with  it  that  vocabulary  necessary  to  express  the  new 
ideas  and  relations.  Part  of  this  new  vocabulary 
came  by  modifying  the  meaning  of  old  words,  part 
by  the  acquisition  of  foreign  or  newly  manufactured 
words.  While  barbarism  and  a  patriarchal,  tribal 
society  lasted,  no  child  was  the  exclusive  son  and  heir 
of  anybody,  and  no  child  was  therefore  an  orphan. 
This  word  and  the  idea  is  stands  for  came  with  pri- 
vate property  and  the  exclusive  family.  In  the  Greek, 
orphanos,  from  which  our  word  is  derived,  was  used 
as  early  as  Homer  (Odyssey,  20,  68).  It  was  taken 
into  the  English  language  by  way  of  the  French  bal- 
lads, which  were  translated  into  the  vernacular  of 
Britain  about  1300-1350,  and  appears  in  "Kyng  Alis- 
aunder"  (line  4947)  : 

"Another   folk  woneth  there  beside, 
Orphani  hi  hatteth  wide." 


ORPHANOTROPHISM.  203 

Then  the  bard  goes  on  to  say  that  these  distant 
people  had  so  many  orphans  because  of  a  kind-hearted 
custom  which  eliminated  the  feebly  aged  at  the  hands 
of  the  children. 

In  Caxton's  Chivalry  it  appears  also  (1484)  in  the 
lines,  "The  office  of  a  knyght  is  to  mayntene  and  de- 
fende  wymmen,  widowes  and  orphans."  (13.) 

Even  in  the  earliest  years  of  orphan-mungering,  the 
evil  effects  of  institutions  upon  the  child  were  ob- 
served and  recorded.  In  North's  Plutarch  we  find 
the  following:  "Orphanage  bringeth  many  discom- 
modities to  a  child."  (185.) 

We  endure  our  abuses  of  orphanotrophism  even 
when  they  are  repulsive  to  the  heathen  Chinee.  In 
the  London  Daily  Neivs,  of  December  16,  1871,  we 
learn  that  the  Chinese  government  "demands  the  sup- 
pression of  the  foreign-  orphanages." 

There  are  many  derivatives  of  the  root  orphan  in 
our  dictionaries.  Each  stands  as  a  blatant  witness  of 
our  cruelty  to  children. 

There  is,  however,  a  continent  in  which  orphan,  or- 
phanage and  orphan  asylums  are  unknown  in  the  legal 
code.  In  fact,  it  is  a  continent  without  an  orphan, 
and  their  vernacular  no  longer  needs  so  cruel  a  word 
except  for  historical  purposes.  America  is  without  a 
lunatic  asylum ;  a  few  States  have  insane  asylums,  a 
few  more  hospitals  for  the  insane,  and  most  of  them 
have  State  hospitals,  but  the  insane  are  still  with  us. 
Australia,  however,  does  not  have  an  orphan  asylum 
nor  an  orphan.  Every  destitute  child  is  at  once  moth- 
ered and  fathered  by  the  State.  The  foundling,  the 


204  ESSAYS. 

deserted  child  and  those  bereaved  by  death  are  at 
once  the  children  of  the  State  and  the  Children's 
Council  is  their  guardian. 

It  came  about  in  this  way:  When  South  Australia 
was  a  small  community  a  certain  Miss  Clark  and  the 
late  Miss  Catherine  Spence  undertook  to  place  out 
among  farmers  the  destitude  children  of  Adelaide.  At 
first  they  served  without  legal  authority,  but  later  they 
secured  an  act  establishing  a  Children's  Council.  All 
matters  relating  to  dependent,  delinquent  and  defec- 
tive children  were  placed  in  the  hands  of  this  Council. 

The  destitute  child  is  taken  to  the  Children's  Court 
and  placed  in  the  care  of  the  Children's  Council.  He 
is  then  boarded  out  in  a  good  family.  If  he  has  a 
sister,  she  is  placed  with  him.  These  children  and 
their  home  surroundings  are  regularly  visited  by  a 
voluntary  local  inspector,  by  a  paid  traveling  inspec- 
tor, by  a  local  paid  physician  and  by  a  local  police  offi- 
cer. Written  reports  are  made  to  the  Council.  Once 
a  year  one  member  of  the  Council  visits  the  home  and 
the  child. 

When  the  child  is  of  school  age,  the  schoolmaster 
sends  in  a  monthly  report  to  the  Council  as  to  the 
child's  parents.  The  child  is  one  of  the  children  of 
the  State,  and  no  longer  either  an  orphan  or  a  pauper. 
The  law  of  the  Continent  kuows  no  such  thing  as  an 
orphan,  even  the  press  and  vulgar  conversation  echew 
the  word.  It  is  cast  out  of  the  living  vernacular  with 
a  long  series  of  words  which  could  be  mentioned,  if 
the  printer  would  not  refuse  to  set  them  up. 

When  the  child  is  of  sufficient  age  and  strength  he 


ORPHANOTROPHISM.  205 

is  allowed  out  of  school  hours  to  work  for  wages, 
which  are  deposited  to  his  credit  in  the  postal  savings 
bank.  When  he  approaches  such  an  age  or  condition 
as  to  require  or  desire  schooling  or  apprenticeship  at 
a  distance,  his  preceptor  inxthe  Children's  Council  rec- 
ommends some  such  course,  and  he  is  allowed  to  use 
his  savings  in  continuing  his  education. 

If  the  child  is  defective  or  delinquent,  he  does  not 
pass  out  of  the  care  or  control  of  the  Council  on  com- 
ing of  age.  The  problem  of  the  defective  child  is  little 
better  solved  in  Australia  than  with  us ;  however,  the 
sources  of  defective  children  are  strenuously  guarded. 
Employers'  liability  insurance,  the  public  ownership 
of  the  unoccupied  land,  graduated  inheritance  taxes, 
graduated  land  taxes,  graduated  income  taxes,  personal 
responsibility  for  corporate  crime  and  other  evidences 
of  corrective  legislation  favorable  to  the  young  and  the 
unborn,  are  all  designed  to  favor  parenthood  and  secure 
for -every  child  a  childhood  free  from  toil.  Our  coun- 
try is  possessed  of  innumerable  orphan  asylums  where 
100,000  children  languish.  These  orphanotrophies,  as 
Johnson  calls  them,  make  the  poorest  citizens  possible 
out  of  our  orphans.  The  death-rate  in  all  foundling 
and  orphan  asylums  is  so  terrible  that  less  than  a  tithe 
survive  the  first  five  years.  Even  those  that  live  are 
scuttled  by  disease.  They  have  spectacles,  but  cannot 
see ;  running  ears,  and  cannot  hear ;  adenoids,  but  can- 
not sleep  without  snoring,  and  enlarged  tonsils,  but 
hardly  escape  rheumatism,  gastric  ulcer  and  appendi- 
citis. They  do  not  learn  to  live  outside  of  an  institu- 
tion. Consider  what  is  open  to  a  boy  or  a  girl  brought 
up  in  a  great  orphanotrophy,  steam-heated,  the  fires 


206  ESSAYS. 

under  whose  boilers  never  go  out  from  one  year's  end 
to  another!  He  cannot  build  a  fire,  do  the  chores 
about  a  house,  care  for  a  horse  or  stable,  milk  a  cow 
or  feed  and  harness  horses.  He  does  not  know  even 
the  names  of  ordinary  household  duties.  He  cannot 
care  for  his  room  or  his  own  clothes.  The  girl  is  even 
worse  off,  if  possible. 

Our  homing  societies  are  private,  unauthorized  and 
unsupported.  If  they  place  children  out,  they  lose  all 
authority  and  control  over  both  child  and  foster  par- 
ent. Many  serious  conflicts  thus  arise,  which  bring 
discredit  upon  the  method  and  bolster  up  the  child- 
devouring  orphanage. 

1.  The  orphan   asylum    is   a   cruel    Moloch   which 
destroys  the  children  placed  in  its  care,   a  disgrace 
to  society  in   feeding  the  brothels  and  adorning  the 
rogues'  gallery,  in  putting  out  defectives  and  incom- 
petents into  the  labor  market  to  beat  down  wages  in 
the  lowest  trades,  an  expense  to  the  State  which  must 
ultimately  pay  dear  for  delinquency  which  benevolent 
but  unthinking  cruelty  to  the  child  surely  entails. 

2.  Placing  out  the  dependent  child  without  author- 
ity, by  private  societies,  is  inadequate  and  scandalous, 
and  has  the  merited  disapproval  of  the  public. 

3.  The  only  adequate,  rational,  humane,  economic 
and  safe  method  of  disposing  of  the  dependent  infant 
is  the  method  of  Australia,  the  permanent  adoption  of 
child  by  the  State,  with  all  its  authority,  its  resources, 
its  organization  for  control,  sustenance,  guidance,  in- 
spection and  education ;  namely,  placing  out  with  fos- 
ter parents,  with  authority,  compensation  and  inspec- 
tion. 


THE  BURIED  TREASURE,  OR  THE  NEG- 
LECTED ABBOTT  OF  BRUNN. 


THE  present  age  values  everything  in  gold,  and  cheap- 
est of  all  things  is  the  man.  Yet  when  we  look  at  the 
advances  of  civilization  we  can  see  innumerable  illus- 
trations of  the  fact  that  man  is  all  and  everything  in 
the  progress  of  the  world — Socrates,  Phideas,  Michael 
Angelo,  Raphael,  Cuvier,  Agassiz,  Galvani,  Faraday, 
Pare,  Pasteur,  Koch,  Ehrlich,  Darwin  and  Mendel. 

In  a  recent  editorial  in  THE  LANCET-CLINIC  refer- 
ence was  made  to  the  buried  and  forgotten,  but  at  last 
epoch-making,  contribution  of  Gregor  Mendel  to  the 
proceedings  of  a  provincial  society  of  natural  history. 
Credit  was  given  to  Hugo  de  Vries  alone  for  the  dis- 
covery of  the  long-neglected  contribution  of  the  Ab- 
bott of  Brunn. 

If  it  is  permitted  me  to  make  a  correction  and  ex- 
planation, two  other  investigators,  C.  Correns  and 
Erich  Tschermark,  presented  papers  to  the  German 
Botanical  Society  (Deutsdie  botanisclie  Gcsellschaft) 
in  the  early  half  of  the  same  year,  showing  a  familiarity 
with  Mendel's  work  and  extending  and  confirming  his 
observations  and  deductions.  Each  author  announced 
Mendel's  priority,  gave  him  credit  and  praised  the 
fidelity  of  his  observations,  the  unexcelled  and  unmis- 
takable method  of  his  analysis  and  the  masterly  pres- 
entation of  his  deductions. 

Besides  a  few  notes  on  natural  science  while  he  was 
a  student  in  Vienna  and  three  or  four  papers  presented 

207 


208  ESSAYS. 

to  the  local  society  on  extraneous  scientific  subjects, 
Mendel's  fame  as  an  epoch-making  observer  and  phi- 
losopher rests  on  a  single  article  which  he  presented 
to  the  Academy  of  Sciences  of  Briinn  on  March  8, 

1865,  and  published  in  the  proceedings,  vol.  v,  p.   1, 

1866.  This  paper  was  about  forty-four  pages  long, 
without  illustration.    The  proceedings  were  exchanged 
with  other  learned  societies  and  went  into  the  libraries 
of  the  world,  but  the  original  is  difficult  to  consult. 
However,  a  reprint  has  been  issued  which  can  easily  be 
secured   (Ostwald's  Klassiker    der    exakten    Wissen- 
schaft,  No.  121),  and  a  translation  made  by  Bateson 
(Mendel's  Principles  of  Heredity,  Cambridge  Univer- 
sity Press,  1909,  8vo,  pp.  317-361,  also  Annual  Report 
of  Board  of  Regents  of  the  Smithsonian  Institution, 
1902,  pp.  557-580).     It  is  possible  to  get  an  abstract 
and  an  illustrated  presentation  of  Mendelism  from  J. 
Arthur  Thompson's  "Heredity"'  (1907),  chapter  x,  p. 
336.     This  book  is  in    every  public  library.     A  very 
delightful  little  book  by  R.  C.  Punnet  (Macmillan  & 
Co.,  London,  small  octavo,  pp.  85,  about  50  cents)  on 
Mendelism   is   particularly   adapted    to    fanciers    and 
naturalists  who  would  like  to  verify  the  law. 

The  forty  pages  of  observations  covering  eight  years 
and  the  analyses  and  deductions  which  have  changed 
the  philosopsy  of  the  world,  can  be  read  in  a  few 
hours.  The  epoch-making  experiments  were  conducted 
on  the  garden  pea  and  within  the  enclosure  of  a  mon- 
astery, by  an  isolated  monk. 

Only  one  author  referred  to  Mendel's  contribution 
from  its  publication  in  1866  to  its  simultaneous  dis- 


THE  BURIED  TREASURE.  209 

covery  by  de  Vries,  Correns  and  Tschermark  in 
March-June,  1900.  Focke  Pflanzennischinge,  1881, 
pp.  109-110)  briefly  and  without  appreciation  mentions 
Mendel's  work  and  compares  it  to  Knight's.1 

We  must,  however,  be  grateful  to  Focke  for  this 
brief  mention,  for  by  so  slight  a  thread  were  both  de 
Vries  and  Correns,  and  possibly  Tschermark  guided 
to  this  important  paper. 

In  this  connection  we  must  not  fail  to  mention  Peter, 
who,  in  1884,  the  year  of  Mendel's  death,  referred  in 
an  article  on  hybridism  in  the  Botanische  Jahresbucher, 
vol.  v,  p.  201  et  seq.  and  esp.  212,  to  Focke  and  twice 
to  Mendel. 

It  is  probable  that  other  mention  of  Mendel's  work 
will  be  found  by  readers,  and  it  is  more  than  likely 
that  I  have  overlooked  sources  of  information. 

Mendel's  disappointment  at  the  silence  with  which 
his  work  was  received  was  great  if  not  bitter.  He 
often  asserted  that  his  time  would  come  yet.  He  went 
on  with  other  experiments  on  bees  and  got  queens  from 
every  part  of  the  world.  A  few  traditions  among  the 
monks  and  a  few  old  beehives  are  all  that  is  left  to 
console  us  for  what  we  believe  we  have  lost. 

In  the  early  months  of  1900  the  knowledge  of  Men- 
delianism  burst  forth  upon  the  world.  The  succession 
was  about  as  follows : 

On  March  26  an  abstract  of  some  work  showing  the 
results  of  de  Vries'  work  was  presented  to  the  Acad- 
emy of  Sciences  of  Paris  by  Gaston  Bonnier  (Compt. 
rend.,  T.  130,  pp.  842-847). 

1  Libraries  to  which  I  have  access  do  not  have  Focke's  work, 
and  my  information  comes  from  Bateson. 


210  ESSAYS. 

On  March  14  de  Vries  presented  to  the  Deutsche 
botanische  Gesellschaft  his  complete  paper,  and  he  read 
the  same  at  the  meeting  March  30,  1900.  It  was  pub- 
lished in  the  Bericht,  vol.  18,  p.  83.  In  this  paper  he 
distinctly  credits  Mendel,  and  says  that  he  was  led  to 
discovering  Mendel's  article  by  following  Focke's  ref- 
erence (footnote  on  p.  85). 

After  reading  de  Vries'  abstract  in  Cotnpt.  rend., 
T.  130,  Correns  completed  his  article  on  a  similar  sub- 
ject, in  which  he  referred  to  Mendel  and  said  distinctly 
that  he  ran  down  his  article  through  Focke's  reference, 
and,  on  April  22  he  sent  it  to  the  German  Botanical 
Society.  It  was  received  on  April  24  and  read  at  the 
meeting  of  April  27,  and  published  in  the  Bericht,  vol. 
18,  pp.  158-167.  After  its  presentation  Correns  for 
the  first  time  saw  de  Vries'  complete  article  in  the 
Bericht  and  learned  for  the  first  time  that  he  was  not 
the  only  discoverer  of  Mendel. 

On  June  2,  1900,  Tschermark's  article  recounting  his 
eight-year-long  observations  on  garden  peas  was  re- 
ceived by  the  society.  He  also  discovered  that  de  Vries 
and  Correns  had  anticipated  him,  but  as  he  had  been 
several  years  in  confirming  Mendel's  observtaion,  he 
counted  himself  fortunate  in  his  association  with  de 
Vries  and  Correns  in  the  discovery  of  Mendel.  His 
paper  was  presented  at  the  meeting  of  June  29,  and 
published  on  pp.  232-239  of  the  Bericht  dcr  Deutsche 
botanische  Gcselhchaft,  vol.  18. 

From  1862  onward  hybridism  and  heredity  had 
been  prominent  studies  both  among  botanists  and 
zoologists.  How  was  it  possible,  then,  for  this  simple, 


THE  BURIED  TREASURE.  211 

brief,  lucid  exposition  of  a  series  of  experiments  with 
the  garden  pea  to  be  hidden  in  forgetfulness  and  ob- 
scurity ? 

This  romance  or  tragedy  of  science  has  given  more 
pleasure  in  its  pursuit  than  I  can  expect  any  reader  will 
gain  from  its  perusal,  but  I  can  only  hope  that  the  trail 
will  be  found  lopped  out  so  that  the  interested  student 
may  find  fewer  difficulties,  though  he  may  be  robbed 
of  some  of  the  scout's  pleasures. 

The  meager  incidents  of  Mendel's  life  which  have 
been  made  public  have  been  briefly  set  down  by  Bate- 
son.  We  hope  for  the  resurrection  of  further  material 
for  a  biography ;  for  everyone  is  interested  in  the  man 
who  has  so  stirred  the  world  of  thought,  made  heredity 
a  science,  opened  the  door  to  a  rational  eugenics  and 
rung  the  bell  for  a  new  social  order. 


BLESSED  ARE  THE  MEEK,  FOR  THEY  SHALL 
INHERIT  THE  EARTH. 


IT  was  a  shock  to  our  complacency  to  learn  through 
the  press  that  Iowa  had  actually  lost  in  population  by 
the  last  census  more  than  7,000  inhabitants,  and  fallen 
from  the  tenth  to  the  thirteenth  rank  in  population. 
We  had  thought  of  Iowa  as  the  ideal  granger  State. 
All  of  our  hopes  of  rural  life  centered  in  this  great 
commonwealth  of  unequalled  natural  resources  and 
most  fortuitous  ethnic  stock.  The  loss  of  7,082  in- 
habitants or  0.3  per  cent.,  without  an  earthquake  or 
poor  crops,  or  a  visitation  of  locusts,  or  an  invasion  of 
disease,  disturbed  all  our  preconceived  notions. 

The  further  press  report  that  more  than  one-seventh 
of  the  loss  of  population  in  the  whole  State  was  suf- 
fered by  one  count}-  aroused  the  hope  that  it  would  be 
possible  to  discover  the  cause  by  giving  especial  atten- 
tion to  that  locality.  Wayne  County  therefore  has  at- 
tracted our  attention,  and  we  have  made  these  studies, 
at  a  distance,  to  be  sure,  and  still  wish  more  direct  in- 
formation. 

The  population  of  Wayne  County,  fourteeen  town- 
ships, 528  square  miles,  was  17,491  at  the  1900  cen- 
sus. Our  present  information  shows  that  it  has 
lost  nearly  6  per  cent,  during  the  last  ten  years,  and 
now  numbers  16,184,  a  loss  of  1,307  inhabitants.  Al- 
most every  acre  of  land  in  the  county  is  productive.  It 
is  on  the  Missouri  boundary,  half-way  between  the 
Mississippi  and  Missouri  Rivers,  on  a  sort  of  water- 

213 


214  ESSAYS. 

shed.  It  was  described  by  State  Geologist  Chas.  A. 
White,  in  his  first  annual  report  (1868,  pp.  40-42),  in 
the  most  poetic  and  appreciative  manner  as  the  ideal 
rolling  prairie  of  the  State. 

The  first  settler  of  the  county  was  H.  B.  Duncan, 
who  came  up  from  Missouri  in  1841,  and  was  followed 
by  sturdy  Scotch  pioneers  in  great  numbers.  In  Feb- 
ruary, 1851,  Dr.  Isaac  McCarty  organized  the  county, 
and  a  bitter  fight  began  over  the  location  of  the 
county  seat,  the  bkterness  of  which  still  rankles  in 
the  breasts  of  the  present  inhabitants  of  rival  cross- 
roads on  the  prairie.  In  1852  the  population  of  the 
county  was  749;  in  1860  it  was  6,409;  in  1870  it  was 
11,287;  in  1880  it  was  16,127;  in  1890  it  was  16,155  ;  in 
1900  it  was  17,491,  and  in  1910  it  had  retrograded 
1,307,  and  was  16,184.  Even  in  1880  there  were  only 
454  persons  of  foreign  nativity  in  the  county  and  only 
22  colored  persons,  which  number  fell  to  15  in  1895. 
The  proportion  of  males  and  females  in  1880  was  1,000 
— 965,  and  the  proportion  of  adults  to  infants  five 
years  and  under  was  above  the  average  for  the  State. 
In  1895  the  population  of  the  county  was  16,155,  50.7 
per  cent,  adults,  twenty-one  and  over,  and  2,086  were 
five  years  and  under,  12.2  per  cent.  At  this  time  51.9 
per  cent  of  the  population  of  the  State  were  adults 
over  twenty-one  years  old,  and  only  23.72  per  cent,  ten 
years  old  and  younger. 

From  the  earliest  times-  the  people  have  been  almost 
violently  religious  and  sectarian,  and  the  church  has 
been  a  large  element  in  the  social  life  of  the  county — 
for  good  or  evil.  In  1855  there  were  five  churches  in 


BLESSED  ARE  THE  MEEK.  215 

the  county.  In  1906  there  was  not  a  Catholic  church 
and  not  a  Catholic  reported  in  the  county,  but  there 
were  2,103  Methodists,  1,360  Campbellites  (Disciples 
of  Christ),  and  1,128  Baptists.  In  Wayne  County  it 
means  something  to  belong  to  one  of  these  churches. 
All  social  and  even  material  interests  are  influenced  by 
the  church.  The  marriages  of  conflicting  church  mem- 
bers or  church  members  with  outsiders  is  almost  as 
serious  an  offense  as  miscegenation  with  the  colored 
races.  The  results  are  marriages  of  cousins  and  others 
near  of  kin.  All  the  Presbyterians,  for  example,  are 
now  related,  by  marriage  at  least,  and  the  church  be- 
comes a  social  club  which  opens  and  closes  its  doors 
on  economic  opportunity. 

Most  of  the  farms  are  occupied  by  the  owners  or 
some  member  of  the  owner's  family.  Less  than  one- 
third  of  the  farms  are  rented,  and  rarely  then  to  stran- 
gers. The  farms  are  not  large,  only  one  of  more 
than  900  acres  (Bracewell's).  There  have  been  very 
few  transfers  of  real  estate  in  the  county  during  the 
last  ten  years.  The  reports  as  to  indebtedness  are  not 
recent,  but  they  show  a  fine  condition  and  clear  title 
in  the  present  owners.  There  has  been  little  emigra- 
tion from  the  county  to  newer  localities.  The  young 
people  do  not  leave  for  the  city  as  they  do  from  many 
rural  localities.  They  stay  at  home,  and,  since  economic 
conditions  do  not  prevent,  they  marry  young,  21-24 
for  men  and  younger  for  women.  These  marriages 
are  fixed  up  by  the  dictates  of  agricultural  propinquity, 
church  membership  and  even  consanguinity  rather 
than  by  passion  or  love.  Every  now  and  then  a  couple 


216  ESSAYS. 

are  married  to  legitimize  an  expected  child,  and  the 
young  people  are  separated  at  once  if  it  is  considered 
a  misalliance  and  a  divorce  follows  in  due  time. 

In  the  whole  State  of  Iowa  divorces  have  greatly 
diminished  during  twenty  years.  There  were  34,874 
divorces  in  Iowa  between  1887  and  1906,  averaging 
about  2,300  a  year  at  the  beginning  and  1,100  a  year 
at  the  end  of  the  twenty-year  period.  During  the  same 
time  there  were  242  divorces  in  Wayne  County,  about 
15  a  year  at  the  beginning  and  6  a  year  at  the  end  of 
the  period ;  to  be  exact,  8,  7,  6,  3  during  the  years 
1903-1906. 

Probably  nothing  is  more  difficult  to  get  information 
about  than  the  sexual  and  reproductive  life  of  a  peo- 
ple. There  is  no  registration  or  vital  statistics  in  Iowa 
or  in  Wayne  County,  so  we  can  only  take  the  testi- 
mony of  the  newspapers  and  medical  men.  It  is  our 
opinion  that  abortions  are  not  habitual,  and  that  the 
people  do  not  generally  practice  maneuvers  for  the 
prevention  of  conception.  We  do  know  for  a  fact 
that  many  families  consult  physicians  for  means  of 
securing  impregnation,  and  that  several  curettements 
of  the  uterus  have  been  performed  with  that  end  in 
view,  as  well  as  many  less  serious  operations.  A  great 
many  families  are  sterile  when  there  is  every  reason 
to  believe  they  are  without  venereal  infection  and  were 
married  young  and  have  never  practiced  any  methods 
designed  to  prevent  conception.  It  is  the  opinion  of 
one  close  observer  that  the  Presbyterians  are  the  most 
uniformly  sterile  and  the  Campbellites  next.  The 


BLESSED  ARE  THE  MEEK.  217 

Methodists  seem  to  her  to  be  the  most  uniformly  pro- 
lific. 

There  is  one  town  in  the  county  of  2,900  inhabitants 
and  only  a  small  floating  population — few  Jews,  no 
negroes  and  no  raw  foreigners.  Most  of  the  in- 
habitants of  the  county,  as  in  1880,  are  native  born 
and  descended  from  the  first  pioneers  of  the  1850's — 
Scotch,  English,  American  stock.  A  rather  large  pro- 
portion of  the  people  are  large  blondes  with  broad 
heads,  but  a  good  minority  are  little  brunettes  with 
small  heads,  resembling  the  best  brunette  stock  from 
the  fastnesses  of  Scotland  and  Wales. 

There  are  13  dependents  on  the  poor  farm  of  240 
acres,  and  the  county  paid  $6,480  for  the  care  of  the 
insane  last  year. 

There  is  little  wheat  raised  in  the  county,  but  corn, 
oats  and  other  grains  exceed  the  average  per  acre  of 
the  State.  A  small  part  of  the  county,  less  than  six 
square  miles,  are  underlaid  with  coal  measures. 

The  wells  are  usually  open  and  fifteen  to  twenty-five 
feet  deep,  but  there  are  some  drilled  wells  getting  pure 
water  below  the  rock.  The  wells  are  close  to  the 
houses  and  barns,  and  rarely  provided  with  windmills 
or  gas  engines  for  pumping.  The  farmhouses  are  en- 
tirely and,  we  believe,  without  exception,  devoid  of 
water  closets,  and  only  exceptionally  provided  with 
sinks.  Many  of  these  sinks  are  without  outlets  or 
inlets. 

Tiie  houses  are  large,  but  not  adapted  to  easy  house- 
keeping and  the  arrangements  are  not  stfth  as  to  en- 
courage  social  life  by  surrounding  gardens,  tennis 


218  ESSAYS. 

courts,  garden-houses  and  shelters.  In  passing  through 
this  rich  county  one  is  struck  by  the  lack  of  material 
evidences  of  culture  as  compared  with  far  less  pros- 
perous regious  in  Xew  England,  England  and  Ger- 
many. 

With  such  a  water  supply  and  such  neglect  of  the 
refinements  of  country  life  it  is  not  remarkable  to  hear 
that  typhoid  is  endemic.  It  is  no  unusual  occurrence 
for  every  member  of  a  family  to  come  down  with 
typhoid  fever  without  the  slightest  investigation  by 
town,  county  or  State  officers  of  health.  Any  local 
physician  who  would  question  the  potability  of  the 
water  of  the  family  well  or  the  respectability  of  the 
ancient  privy  with  its  fly-breeding  vault  would  not 
only  lose  practice  in  the  family,  but  in  the  whole 
church  to  which  that  family  was  attached. 

The  after-effects  of  typhoid  are  also  prevalent — 
sick  headache,  jaundice,  colic  and  nervous  disorders 
are  the  regular  inheritance  of  most  of  the  people  in 
the  fifties  and  sixties. 

There  are  remarkably  few  cases  of  syphilis  observed 
in  the  county.  After  each  Chautauqua  assembly  the 
young  doctors  have  a  lot  of  gonorrhea  to  treat  among 
the  boys  and  girls  about  twenty,  and  a  few  patients 
have  been  operated  on  for  pyosalpinx  during  the  past 
five  years. 

If  we  are  asked  now  why  Wayne  County  has  lost  in 
population,  we  can  only  make  a  negative  reply.  The 
growth  of  population  depends  upon  many  factors  and 
no  simple  answer  is  possible. 


BBLESSED  ARE  THE  MEEK.  219 

1.  The  loss  of  population  is  not  due  to  alcohol,  or 
vice,  or  poverty. 

2.  The  loss  of  population  is  not  due  to  the  sterility 
of  gonorrhea.     (One-child  families,  so  characteristic 
of  gonorrhea,  are  extremely  rare). 

3.  The  loss  of  population  is  not  due  to  emigration  to 
the  city  or  to  new  countries. 

4.  The  loss  of  population  is  probably  (in  the  face 
of  no  vital  statistics)  due  to  a  falling  birth-rate.     (In 
the  State  of  Iowa  the  birth-rate  is  low  in  1900,  as  in- 
dicated by  the  percentage  of  children  five  years  old 
and  younger  to  the  total  population.     Iowa  was  11.8 
per  cent.,  the  continental  United  States  12.1  per  cent. 
We  have  no  statistics  from  Wayne  County.) 

5.  The  loss  of  population  is  a  rebuke  to  smuggism, 
orthodoxy,  Yankeeism  and  American  self-complacency. 
It  shows  how  the  inbreeding  of  a  good  stock  under  in- 
sanitary environment  may  deteriorate. 

If  we  might  suggest  a  remedy  for  this  decadent 
community  we  would  urge  the  establishment  of  schools 
of  farmhouse  hygiene,  schools  of  country  architecture, 
and  gardening,  schools  of  outdoor  amusements,  and 
schools  of  household  decoration.  The  universities 
could  easily  spare  the  teachers  from  the  candidates 
for  the  doctor's  degree. 

\Vayne  County  has  the  natural  resources  and  the 
sturdy  stock.  It  has  the  freedom  from  the  dangerous 
celestial  and  the  disturbing  negro,  as  well  as  freedom 
from  the  despised  labor  unions  which  many  look  upon 
as  the  curse  of  the  city.  What  Wayne  County  needs  is 


220  ESSAYS. 

ideals.  The  dry-rot  of  smuggery  and  self-complacency 
is  making  punk  of  this  favored  community. 

The  State  of  Iowa  is  in  much  the  same  condition. 
Of  the  ninety-nine  counties  only  ten  counties,  all  con- 
taining cities,  have  gained  in  population ;  the  other 
eighty-nine  have  lost. 

The  question  is,  what  are  we  going  to  do  about  it? 
The  State  of  Iowa  should  be  a  veritable  garden  and  a 
kindergarten.  It  remains  true  to  the  traditions  of  the 
last  century,  a  prairie  State.  The  towns  grow,  and 
even  make  progress  in  ideas  and  ideals,  but  the  country 
languishes.  The  learned  professions  should  take  a 
hand  in  the  regeneration  of  the  stock  that  made  the 
conquest  of  this  continent  a  miracle. 


PROFESSIONAL  AND  SURGICAL 


THE  COUNTRY  DOCTOR  AND  TYPHOID. 


No  DISEASE  is  better  understood  by  American  physi- 
cians than  typhoid.  It  is  a  condition  which  is  little 
influenced  by  medication,  but  marvelously  modified  by 
the  watchful  physician  and  the  alert  nurse.  To  the 
individual  typhoid  is  a  terrible  calamity  which  has  a 
high  le^ith-rate  and  a  kaleidoscope  of  sequences  which 
is  a  nightmare  to  contemplate.  To  the  community 
typhoid  is  a  disgrace  which  'should  call  for  as  promp'; 
and  vigorous  activity  on  the  part  of  the  sanitary  offi- 
cers of  the  police  and  constabulary  show  after  a  mur- 
der. The  itch  was  exterminated  by  soap,  cheap  linen 
and  single  beds.  It  was  a  disease  of  the  individual, 
or  at  least  of  the  household.  Typhoid  is  a  community 
disease.  The  death-rate  from  typhoid  has  been  ai- 
most  entirely  eliminated  from  our  cities  by  the  mu- 
nicipal water  supply  and  the  sanitary  supervision  of 
the  milk  supply.  The  small  towns  and  the  country  arc 

still  disgraced  by  typhoid. 

*      #      * 

As  the  source  of  public  opinion  in  matters  of  health 
we  cannot  remain  silent  on  the  typhoid  question. 
Every  typhoid  patient  should  be  treated  as  our  sci- 
ence dictates  (over  which  there  is  no  dispute),  and 
the  occurrence  of  typhoid  should  arouse  a  hunt  for 
the  worse  than  murderous  contagion  that  caused  it. 
When  the  two  man-eating  lions  stopped  the  railroad 
building  in  East  Africa,  they  attacked  and  destroyed 
fewer  men  than  are  now  at  death's  door  in  many  a 

223 


224  ESSAYS. 

county  in  this  enlightened  country.  The  further  rav- 
ages of  the  disease  could  be  stopped  by  less  effort, 
with  less  danger  and  in  a  shorter  time  than  it  took  to 
capture  those  two  lions. 


Diphtheria  is  conquered;  wound  infections  are  pre- 
ventable ;  hospital  gangrene  is  exterminated ;  tetanus 
is  cornered  and  the  terror  of  tuberculosis  is  much  al- 
layed; but  typhoid,  when  once  begun,  must  be  care- 
fully watched  to  the  end.  We  know  its  cause,  we  have 
an  exact  method  of  diagnosis,  but  our  only  service  and 
skill  lies  in  exterminating,  destroying,  obliterating 
and  even  anticipating  its  source.  Don't  tell  us  that 
you  save  all  or  nearly  all  your  typhoids.  Tell  us,  how- 
ever, that  you  found  the  source  of  infection  in  every 
case  and  that  you  succeeded  in  overcoming  it  before 
a  second  case  appeared.  When  diphtheria  shows  itself 
in  a  family  the  patient  is  given  a  full  dose  of  the 
antitoxin  and  each  of  the  other  members  of  the  family 
an  immunizing  dose.  The  family  is  segregated  from 
the  public.  No  physician  can  hold  himself  guiltless  when 
he  fails  to  institute  these  precautions.  A  second  ty- 
phoid in  a  family  casts  merited  suspicion  on  the  medi- 
cal man  who  cared  for  the  first  case.  The  problem  is 
not  so  obvious  as  our  illustration  above,  but  the  logic 
is  as  binding.  A  succession  of  cases  of  typhoid  ought 
to  arouse  activity  in  the  medical  society  of  the  town, 
and  the  delinquent  physician  should  be  labored  with 
arid  shown  how  greatly  his  neglect  injures  the  credit, 


COUNTRY  DOCTOR  AND   TYPHOID.  225 

honor  and  influence  as  well  as  the  economic  position 
of  every  member  of  our  profession. 

The  pursuit  of  the  source  of  typhoid  infection  is  not 
so  simple  as  to  be  devoid  of  interest.  On  the  con- 
trary it  is  one  of  the  most  complicated  and  fascinating 
studies  which  any  physician  can  undertake.  Our  lit- 
erature contains  reports  of  the  pursuit  of  typhoid  in- 
fection as  thrilling  if  not  as  adventurous  as  the  hunt 
of  the  before-mentioned  lions.  The  prescience  of  the 
"good  old  doctor"  is  of  use  in  tracking  the  game 
through  the  mazes  of  modern  industry  and  transpor- 
tation. The  well,  the  milk  man  and  the  much-neg- 
lected servant  question  are  factors  which  must  be 
considered  and  at  last  eliminated. 
*  *  * 

When  the  source  of  the  disease  is  found  there  are, 
especially  in  the  small  community,  many  obstacles  to 
the  obliteration  of  the  danger.  If  ignorance  alone 
is  in  the  way  it  can  be  slowly  dispelled,  but  it  is  only 
too  often  attended  by  prejudice  and  stupidity.  Then 
tact  must  be  used  and  only  as  a  last  resort  the  san- 
itary police  power  brought  in  play.  In  no  other  emer- 
gency of  practice,  not  in  obstetrics,  not  in  surgery, 
can  the  physician  show  himself  such  a  diplomat  and 
such  a  power  as  in  filling  up  an  old  and  long-cher- 
ished well  or  in  remodeling  or  rebuilding  a  sloppy 
dairy.  The  well  and  the  outhouse  are  the  two  great 
sources  of  typhoid  in  the  rural  community,  and  they 
should  be  put  under  ban  as  severe  as  the  housebreaker 
and  the  highwayman. 


226  ESSAYS. 

\\  ith  modern  plumbing,  which  is  not  plumbing  at 
all,  but  steamfitting  and  the  driven  well,  the  rural 
community  ought  to  be  as  safe  from  typhoid  as  the 
city.  The  open  well  is  a  constant  source  of  immeas- 
urable danger,  and  in  spite  of  years  of  innocuousness, 
it  may  at  any  moment,  it  must  at  some  time,  be  a  men- 
ace to  life.  The  driven  well  is  safe  and  permanent. 
Upon  the  whole  it  is  cheap.  Where  it  is  not  available, 
open  wells  are  doubly  dangerous.  The  State  univer- 
sity provides  advice  for  any  particular  locality  in  se- 
curing usable  water  and  makes  tests  to  confirm  the 
suspicion  of  contamination  or  to  refute  it. 

The  abolition  of  open  privies  in  rural  districts  is 
coming  on  rapidly  by  the  dictate  of  fashion.  The 
country  is  full  of  gasoline  engines  and  windmills. 
Every  farmhouse  will  soon  have  its  water  closet  and 
bath  room.  The  septic  tank  is  particularly  adapted 
to  the  purification  of  the  sewage  from  a  private  house. 
The  septic  tank  itself  is  under  ground  and  not  offen- 
sive. The  overflow  is  clear,  almost  odorless  and  harm- 
less. The  whole  apparatus  is  simple,  cheap,  permanent 
and  reliable. 

*     *     * 

The  physician  should  put  his  own  house  in  order 
and  make  his  surroundings  a'  model  for  his  neighbor- 
hood. In  this  effort  he  will  learn  the  practical  and 
realize  his  ideal.  We  never  know  until  we  do.  Life 
is  doing.  The  doctor  should  stand  for  communal  co- 
operation in  seeking  a  water  supply  and  securing 
proper  sewerage  and  garbage  disposal.  Nevertheless, 
until  this  co-operation  is  attained  he  should  make  his 


COUNTRY  DOCTOR  AND   TYPHOID.  227 

own  home  and  surroundings  sanitary,  convenient  and 
attractive.  Let  him  abolish  the  outhouse  and  install 
the  water  closet  and  septic  tank.  Let  him  do  away 
with  the  open  well  and  secure  deep  water  through  a 
driven  well,  a  windmill,  a  gasoline  engine  or  other  de- 
vice. Let  him  surround  his  house  with  a  model  gar- 
den and  do  away  with  the  interminable  rococo  porch, 
the  back  door  stoop  and  general  untidiness  of  the 
average  rural  house.  Let  him  also  make  his  kitchen 
a  model  of  convenience,  cleanliness  and  permanence 
and  the  show  room  of  the  house.  A  house  and  yard 
inseparable,  tidy,  clean,  compact  and  inviting,  even  if 
small,  is  an  asset  for"  a  doctor  which  overcomes  igno- 
rance and  superstition,  Christian  Science,  the  Em- 
manuel movement  and  every  other  form  of  irrational 
competition.  It  will  keep  him  and  his  family  at  home. 
It  will  attract  his  friends  and  neighbors.  It  will  be  a 
model  to  his  patients  and  an  argument  for  following 
his  precepts  in  thus  raising  the  standard  of  his  life. 
Typhoid  will  go  when  the  abominations  on  which  it 
lives  are  superseded. 


THE  SEPTIC  TANK  IN  SEWERAGE 
DISPOSAL. 


Tin-:  need  of  a  higher  standard  of  life  is  emphasized 
by  the  spread  of  the  hookworm  disease  in  the  South 
and  the  ever-present  typhoid  in  the  North.  It  is  left 
to  John  D.  Rockefeller  to  call  the  sleeping  masses 
to  wake  up  to  a  condition  which  most  of  them  never 
heard  of  before,  that  puts  nearly  two  million  South- 
ern white  out  of  the  labor  market.  The  standard  of 
life  of  these  people  is  so  low  that  only  about  one-third 
of  their  residences  have  privies  j1  the  remaining  two- 
thirds  have  no  provision  for  decency. 

The  condition  of  these  poor  whites  is  quite  pitiable, 
but  not  more  pitiable  than  a  much  greater  number  of 
residents  in  the  North,  who  suffer  from  typhoid  in 
ever-increasing  epidemics.2 

The  savage  lived  in  trees,  or  at  least  in  the  woods, 
and  had  little  need  to  fear  his  own  excrement.  It  was 
one  of  the  least  of  his  enemies.  The  barbarian  nomad 
left  his  refuse  and  excrement  to  dry  on  the  plains. 
To  civilized  man  the  disposal  of  his  excrement  marks 
his  rise  or  fall.  At  first  the  household  has  no  pro- 

1  Public  Health  Report?,  October  1.  1909,  xxiv,  Xo.  40. 

2  The    twelfth   census    of   the    United    States   gives    35,379 
hs  from  typhoid  fever  during  the  "census  year,  or  35.4  per 

1,000  deaths.  The  last  English  reports  show  that  in  England 
and  Wales  there  were  only  19.9  deaths  of  typhoid  per  1,000 
deaths  from  all  causes.  Typhoid  is  a  communal  filth  disease, 
of  which  both  guilty  and  innocent  suiter,  and  it  should  be  ex- 
terminated, and  could  be,  as  my  readers  already  know. 

229 


230  ESSAYS. 

vision  for  defecation.  Then  decency  requires  an  out- 
house. At  last  self-preservation  requires  the  destruc- 
tion of  the  fecal  excrement.  \Ye  are  now  in  the  throes 
of  this  last  stage  of  development.  In  the  cities  of  the 
United  States  most  of  the  sewerage  is  dumped  into 
the  rivers,  the  lakes  or  the  sea.  Only  rarely  is  an  ef- 
fort made  to  destroy  the  sewerage  before  it  is  cast 
abroad.  The  cities  are  now  in  about  the  same  position 
communally  as  regards  their  neighbors  as  are  two- 
thirds  of  the  residences  of  the  "poor  whites"  who  have 
no  privies. 

Many  methods  of  destroying  sewerage  have  been 
tried,  but  none  of  them  has  equalled  in  efficiency,  re- 
liability and  adaptability  the  method  of  the  "septic 
tank."  This  is  an  unfortunate  appellation.  Septic  has 
an  ominous  sound.  Its  associations  are  all  unfriendly 
and  dangerous.  The  "septic  tank"  is  a  great  purifier, 
liquefier  and  sterilizer.  It  is  equally  well  adapted  to 
take  care  of  the  excrement  of  the  city  and  of  the  coun- 
try household,  of  the  permanent  population  of  peace- 
ful countries  and  the  moving  armies  of  those  engaged 
in  war. 

The  fecal  discharges  of  each  individual  may  be  con- 
sidered to  be  about  300  grams  (10  ounces)  per  day. 
They  contain  about  150  billion  bacteria  of  more  than 
fifty  sorts.  Only  a  portion  of  these  are  disease-pro- 
ducing. A  large  part  of  the  bacteria  are  dead.  They 
make  up  more  than  half  the  total  mass. 

The  fecal  discharges  of  man  are  far  less  advan- 
tageous to  the  soil  as  fertilizers  than  those  of  the 
herbivora  or  those  of  birds.  In  any  large  quantity 


THE  SEPTIC  TAXK.  231 

they  are  unmanageable.  The  feces,  when  dried  and 
put  on  land  become  very  offensive  when  wet.  If  they 
contain  disease-producing  life  the  moisture  and 
warmth  set  the  disease  carriers  loose  and  make  the 
use  of  human  excreta  for  gardens  very  dangerous. 
The  hook  worm,  typhoid  and  some  of  the  tapeworms 
are  thus  scattered  and  taken  to  n.ew  hosts  by  way  of 
the  vegetation  on  which  they  are  carried  to  distant 
tables — on  strawberries,  radishes  and  other  greens. 

All  methods  of  artificial  sewerage  destruction  that 
are  safe  are  too  expensive  to  be  practical. 

The  ordinary  sewerage  from  a  household  of  five 
people  consists  of  1,500  grams  (50  ounces)  of  fecal 
matter,  5.000  c.c.  of  urine,  and  one  hundred  gal- 
lons, more  or  less,  of  water  containing  precipitated 
soap  from  the  bath  and  much  grease  and  detritus  from 
the  kitchen  sink.  The  grease  is  the  least  perishable 
and  the  most  troublesome  to  dispose  of.  Unless  it  is 
cookd  and  retained  in  some  large  tank  near  the  sink 
it  collects  in  the  sewer  and  holds  all  sorts  of  detritus 
with  it,  and  thus  stops  the  drains  and  puts  the  whole 
sewerage  system  out  of  commission.  Iron  air-tight 
cooling  and  grease-collecting  catch-basins  are  now  pro- 
curable, and,  placed  near  the  kitchen  sink,  protect  the 
system.  They  must  be  opened  and  the  grease  removed 
two  or  three  times  a  year,  depending  on  the  care  of 
the  cook  and  the  size  of  the  catch-basin. 

All  the  rest  of  the  sewerage  is  perishable,  and  con- 
tains within  itself  all  the  elements  of  its  own  destruc- 
tion and  purification.  It  should  be  conducted  into  a 
water-tight  fermentation  tank,  which  should  hold  about 


232  ESSAYS. 

twice  as  much  as  the  maximum  daily  output  from  the 
household.  It  should  be  not  more  than  twenty-five  to 
one  hundred  feet  from  the  house,  and  connected  with 
it  by  hermetically  sealed  pipes  of  glazed  tile  or  iron. 
The  catch-basin,  the  fermentation  tank  and  these  pipes 
should  be  kept  freely  open  to  the  air  by  vents  running 
above  the  roof  or  the  surface  of  the  ground.  The  sep- 
tic tank  and  all  drains  should  be  below  the  frost  line 
and  wholly  unconnected  with  the  gutters  from  the 
roof  or  any  other  irregular  flooding.  Another  distinct 
system  should  take  care  of  the  storm  water. 

The  fermentation  or  septic  tank  should  be  about 
three  feet  deep  and  preferably  longer  than  wide.  The 
sewerage  should  enter  into  it  at  one  end  and  somewhat 
below  the  middle  of  its  lieight,  and  the  exit  should  be 
at  the  opposite  end  and  somewhat  above  the  middle. 
These  pipes  should  be  not  less  than  four  or  more  than 
six  inches  in  diameter  and  sealed  water-tight  into 
the  ends  of  the  water-tight  buried  septic  tank.  The 
outlet  of  the  septic  tank  should  rise  until  it  is  within 
a  few  inches  of  the  top  of  the  tank  and  then  fall  as 
fast  as  possible  toward  its  outlet,  thus  keeping  the 
tank  full. 

The  operation  of  the  septic  tank  is  constant,  uni- 
form and  automatic.  The  house  sewerage  flows  in 
through  a  four-inch  pipe,  and  therefore  slowly,  even 
when  a  bath-tub  is  emptied.  All  the  solid  material 
rolls  slowly  out  and  sinks  to  the  bottom  of  the  tank 
at  once.  The  liquids,  according  to  their  specific  grav- 
ity, rise  to  the  top  or  sink  to  the  bottom.  Some  of 
the  fluid  flows  slowly  out  at  the  exit  at  the  opposite 


THE  SEPTIC  TANK.  233 

end  of  the  tank.  The  contents  of  the  septic  tank  are 
never  agitated. 

The  flora  of  the  septic  tank  soon  becomes  estab- 
lished. The  struggle  to  exist  results  in  the  consump- 
tion of  almost  every  particle  of  solid  matter  and  the 
production  of  soluble  inorganic  substances.  A  very 
thin  film  of  aerobic  micro-organisms  is  generally  pres- 
ent, and  their  preservation  is  attained  by  keeping  the 
outlet  below  the  surface  of  the  tank.  The  sewerage 
which  flows  out  of  the  septic  tank  is  slightly  turbid 
water  of  a  specific  gravity  less  than  that  of  urine.  It 
is  almost  without  odor,  and  it  contains  few  if  any  liv- 
ing pathologic  micro-organisms.  It  can  be  discharged 
into  an  open  ditch  without  producing  offense,  and  can 
be  collected  into  a  pond  which  remains  perfectly  clear, 
summer  and  winter.  If  discharged  into  a  small  run  or 
brook  it  will  not  kill  the  fish  or  pollute  the  stream.  It 
can  be  discharged  into  drainage  tile  without  befouling 
them  or  putting  them  out  of  service.  It  can  be  dis- 
charged into  sandy  soil  by  letting  the  end  of  the  out- 
let pipe  open  under  ground  into  a  hole  filled  with 
stone  or  coarse  gravel. 

For  the  village  or  city  the  septic  tank  is  equally  ser- 
viceable. One  may  be  constructed  by  each  individual, 
but  better  collectively,  one  for  each  block,  with  a 
single  outlet  into  the  sewer  in  the  street.  If  Chicago 
had  a  septic  tank  in  each  block  the  drainage  canal  and 
the  Illinois  River  would  run  clear. 

RESUME. 

1.  The  privy  marks  the  first  step  from  barbarism 
into  civilization ;  the  water-closet  marks  the  next. 


234  ESSAYS. 

2.  The  connection  of  the  water-closets  with  street 
sewers  is  unnecessary,  and  direct  connection  and  the 
pouring  out  of  undestroyed  sewerage  into  the  street 
drain  is  undesirable  and  dangerous. 

3.  The  septic  tank  is  an  efficient,  simple,  automatic 
and  economical  method  of  destroying  and  rendering 
inert  house  sewerage.    It  is  cheap,  clean  and  practical. 

4.  Every  house  that  has  a  chimney  ought  to  have 
a  water-closet,  and  every  water-closet  ought  to  be  con- 
nected with  a  septic  tank. 


THE  DUTY  OF  RAISING  THE  STANDARD  OF 
RURAL  LIFE. 


IT  is  axiomatic  that  the  physician  is  a  citizen.  He  has 
special  privileges  and  unusual  duties.  As  one  who  is 
called  to  learning,  he  should  lead  in  all  cultural  activ- 
ities. He  should  have  a  special  care  of  all  matters 
pertaining  to  the  social,  physical  and  moral  health  of 
his  community.  But  he  ought  to  be  greater  than  his 
profession  and  take  the  broadest  view  of  the  social 
needs. 

In  the  recent  inquiry  into  the  conditions  of  rural 
life,  undertaken  as  a  part  of  the  inventory  of  our  na- 
tional resources  initiated  by  Theodore  Roosevelt, 
many  significant  facts  have  developed.  The  general 
dissatisfaction  of  the  younger  generation  with  farm 
life  is  the  most  pregnant  of  evils.  The  boys  and  girls 
would,  and  do  as  far  as  possible,  leave  the  farm.  The 
cities  are  overrun  with  the  youth  of  the  country. 

In  asking  many  young  men  and  women  who  have 
good  country  homes  and  considerable  financial  re- 
sources, why  they  come  to  the  city,  they  almost  invar- 
iably express  their  distaste  for  the  low  standard  of 
life  on  the  farm  as  compared  with  that  of  the  lowest 
clerk  in  the  city  or  large  town. 

Our  farmers  dress  as  well  as  the  tradesmen  in  the 
city.  The  farmers'  wives  and  children  dress  as  well 
as  those  of  the  tradesmen.  So  far  farm  life  presents 
as  high  a  standard  as  town  or  city  life.  Differences  in 
taste  and  financial  expenditure  alone  make  differences, 

235 


236  ESSAYS. 

especially  in  the  dress  of  women.  The  farm-house 
has  not  kept  up  with  the  housewife's  apparel.  The 
country  house  of  to-day  does  not  compare  favorably 
with  that  of  fifty  years  ago.  It  is  heated  with  hard 
coal  stoves,  with  steam  or  with  hot  water,  but  it  is 
small,  close,  stuffy,  and  artistically  terrible,  externally 
and  internally.  It  is  lighted  with  lamps  instead  of 
candles,  or  with  some  of  the  terrible  mantle  illumina- 
tors, but  the  means  of  making  the  kitchen  and  laundry 
work  easy,  clean  and  dignified  are  for  the  most  part 
wanting.  The  kitchen  is  still  a  scullery.  The  laundry, 
if  there  is  one,  is  not  connected  with  the  gasoline  en- 
gine which  runs  the  dairy  or  grinds  the  feed  in  the 
barn.  The  chambers  may  be  ever  so  hot  with  steam 
or  hot  water,  but  the  toilet  and  bathing  necessities  of 
a  city  house  are  absent.  In  the  matter  of  housing, 
whether  we  consider  it  from  a  hygienic,  a  social  or  an 
artistic  standpoint,  the  farm-house  is  wofully  below 
the  standard  for  the  city.  The  surroundings,  too,  of 
the  farm-house  are  utterly  neglected.  I  lately  exam- 
ined the  surroundings  of  a  long  line  of  farm-houses 
where  the  surrounding  land  was  selling  at  more  than 
two  hundred  dollars  an  acre.  Some  of  them  had  beau- 
tiful trees  about,  but  not  one  in  twenty  showed  any 
care  or  pride  in  the  surroundings,  and  no  effort  at 
what  might  have  been  realized  in  the  way  of  a  garden. 
Our  people  do  not  seem  to  know  what  a  garden  is. 
They  sometimes  have  kitchen  or  vegetable  gardens, 
though  I  must  say  rarely,  and  now  and  then  a  few 
flowers  in  beds,  which  is  termed  a  flower  garden;  but 
to  have  such  an  arrangement  of  the  vicinage  of  the 


STANDARD    OF   RURAL   LIFE.  237 

house  as  leads  to  the  gradual  extension  of  the  resi- 
dence from  the  walled  rooms  to  the  lawn,  the  arbor, 
the  tennis  grounds  or  belvidere,  is  practically  unknown 
among  farmers.  This  condition  is  not  due  to  lack  of 
resources,  but  to  lack  of  taste.  It  is  a  condition  of  as 
much  importance  in  maintaining  the  population  of  the 
country  as  the  location  of  the  well  or  the  proper  feed- 
ing of  the  babies.  The  simplest  farmhouse  may  be 
surrounded  by  a  garden  which  will  at  once  be  a  joy 
to  every  resident  and  visitor,  and  give  health,  content- 
ment and  inspiration  to  every  one  who  is  fortunate 
enough  to  have  entry  to  it. 

The  first  doctor  I  ever  knew  intimately  was  a  far- 
mer in  Elmira,  Stark  County,  Illinois.  He  lived 
in  a  large  house,  surrounded  by  a  large,  old- 
fashioned  garden.  Near  by  he  had  a  nursery  of 
forest  and  shade-trees.  It  was  the  most  interesting 
home  I  have  ever  found  a  doctor  living  in  and  dying 
in.  He  had  a  beautiful  family,  and  I  believe  no  one 
of  his  many  children  has  failed  to  honor  that  home. 
This  man's  work  was  done  among  farmers,  and  he 
added  to  the  resources  of  the  State  by  his  observations 
on  the  diseases  of  farm  crops,  farm  animals  and  for- 
est trees  quite  as  much  as  he  added  to  the  comfort 
and  health  of  his  patients  by  equally  scientific  treat- 
ment and  friendly  counsel. 

The  times  have  changed.  Every  State  now  has  an 
agricultural  experiment  station,  and  the  farmers  read 
the  bulletins  of  the  Department  of  Agriculture,  and  are 
alive  to  selecting  seed  and  sowing  nitrogen-producing 
bacteria.  Farming  as  a  trade  is  well  in  the  hand  of 


238  ESS  A  ¥S. 

the  farmer,  and  he  makes  it  pay;  but  farming  as  a 
profession  or  calling  is  neglected,  and  in  this  sense 
the  American  farmer  is  the  greatest  failure.  The  more 
successful  he  is  in  making  money  the  more  surely  will 
his  children  leave  the  farm  for  the  city,  for  the  town 
or  become  commercial  travelers. 

In  a  number  of  farmhouses  surrounded  with  barns 
and  equipped  with  the  machinery  of  cultivating,  plant- 
ing, harvesting,  feeding  and  marketing,  the  piano  and 
piano-player,  the  graphophone,  and  every  means  of 
culture  which  the  best  books  and  pictures  can  give, 
have  failed  to  induce  the  young  people  to  follow  the 
paternal  occupation.  The  cause  cannot  be  placed  in 
the  lower  standard  of  life  in  these  particular  families. 
It  may  be  looked  for  in  uncongenial  neighbors  or  in 
faulty  education.  The  standard  of  life,  to  effect  any- 
thing, must  be  communal  rather  than  family  or  indi- 
vidual. The  whole  of  rural  life  must  be  idealized. 
Farming  must  not  be  a  trade  for  profit,  but  a  voca- 
tion for  life.  The  farm  must  not  be  looked  upon  as  "a 
plant,"  but  as  "a  home." 

One  of  the  most  subtle  influences  in  our  rural  life, 
distracting  the  minds  and  hearts  of  our  children  from 
the  farm,  is  the  so-called  educational  system.  The 
schools  teach  a  certain  lingo  which  is  termed  the  cur- 
riculum, conceived  without  regard  to  the  child's  body, 
mind,  soul,  or  environment,  and  perpetrated  without 
feeling  or  sympathy  by  immature  or  inexperienced 
spinsters,  in  cheerless,  church-like  surroundings.  The 
country  district  school  is  a  stepping-stone  only  to  the 
town  school,  and  that  to  the  citv  school,  and  thus 


STANDARD   OF  RURAL   LIFE.  239 

from  the  beginning  inevitably  from  the  farm.  The 
education  of  the  district  school  educates  from  the 
farm,  and  in  this  significance  alone  is  educational. 
Not  one  single  hour  in  a  whole  year's  schooling  is  de- 
voted to  idealizing  farm  life.  The  very  attitude  of 
curriculum,  administration  and  teacher  disparages  the 
farm.  The  district  school-house  should  be  architec- 
turally an  honest  and  interesting  building.  It  should 
be  artistically  well  furnished  and  decorated.  The 
teachers  or  teacher  should  be  of  the  rural  class  and  be 
proud  of  living  on  the  land.  lie  should  teach  the  boys 
to  honor  their  fathers,  and  she  should  teach  the  girls 
to  honor  their  mothers.  The  surroundings  of  the 
school-house  should  be  ideal  and  idealized.  The  oc- 
cupations of  the  farm  should  furnish  the  basis  of  the 
curriculum.  It  should  not  be  a  trade  school,  but  a 
school  in  which  the  activities  of  the  farm  are  system- 
atically taught.  It  should  not  be  exactly  manual  train- 
ing or  sloyd,  but  based  on  the  ideals  of  the  best  in 
both. 

It  is  evident  that  our  poorly  supported  district 
schools  could  not  undertake,  each  of  them,  such  a  pro- 
gram. It  would  be  necessary  for  them  to  combine  and 
transport  the  children  to  the  central  or  township  school, 
and  there  provide  the  gardens,  green-houses,  shops 
and  machinery  necessary  to  such  an  education  as  be- 
fits children  who  are  to  live  on  the  farm.  The  normal 
school  would  need  to  be  equally  revivified  and  brought 
to  the  life  of  the  people  for  whom  their  training  is  in- 
tended. The  normal  school  will  then  be  closer  to  the 


240  ESS  Al'S. 

schools  of  agriculture  and  sociology  than  to  the  schools 
of  Latin  and  belles-lettres  than  they  are  to-day. 

The  youth  of  our  land  want  association  and  excite- 
ment, and  for  these  they  go  to  the  city.  The  former 
would  be  encouraged  by  good  roads  and  by  the  inevi- 
table extension  of  the  trolley  and  automobile.  The 
excitement  should  be  furnished'  at  home.  Sports 
should  be  encouraged  in  the  country  as  they  are  in  the 
city.  The  time  spent  in  games  and  in  endurance  tests 
and  tests  of  skill  is  not  time  wasted  when  farming  is 
conducted  for  life  instead  of  for  profit.  The  cere- 
monial forms  also  occupy  too  small  a  part  of  life. 
Festivals,  ^celebrations,  fetes  and  other  social  congre- 
gations should  form  a  growing  part  of  country  life. 
The  pride  of  occupation,  of  local  undertaking  and 
achievement,  as  well  as  of  national  or  social  aspiration, 
should  be  encouraged  by  pageants  and  processions. 

In  bringing  about  a  conscious  development  of  a 
higher  standard  of  rural  life,  the  country  doctor  is 
privileged  to  take  an  enviable  part.  He  may  by  ex- 
ample show  what  may  be  done  in  making  the  home 
convenient,  comfortable  and  inviting.  He  may  dem- 
onstrate the  labor-saving  and  life-saving  decencies  of 
the  city  house  as  applied  under  local  rural  surround- 
ings. He  may  less  easily  than  the  farmer  extend  his 
residence  into  a  garden.  In  the  school,  also,  he  may 
be  helpful,  and  bring  the  merchant  class  of  the  village 
and  towns  to  see  their  interest  in  promoting  a  self- 
respecting,  permanent  rural  community.  It  is  likely 
that  the  trade  of  such  a  community  would  not  only  be 
more  profitable  to  the  village  tradespeople,  but  would 


STANDARD  OF  RURAL  LIFE.  241 

be  easier  to  retain  and  handle,  and  easier  to  keep  away 
from  the  mail-order  houses  and  migratory  "depart- 
ment stores." 

It  is  possible  that  an  active  part  in  ,-nch  a  social 
movement  would  restore  the  doctor  to  that  leading 
place  in  the  community  which  we  must  all  admit  he 
fails  to  inherit  from  his  ancestor  of  fifty  years  ago. 


BLESS  THE  COOK. 


EXCEPT  in  actual  disease  and  even  in  most  diseases  the 
cook,  the  good  cook  at  least,  can  be  relied  upon  to  fur- 
nish the  best  diet.  It  is  a  terrible  state  of  mind  when 
a  person,  sick  or  well,  disregards  the  scriptural  injunc- 
tion so  far  as  to  take  thought  even  to-day  of  what  he 
shall  eat  and  what  he  shall  drink.  In  certain  sani- 
tariums little  else  is  talked  about  than  this  or  that  diet 
and  this  or  that  condition  of  the  natural  functions  of 
the  body.  The  result  is  a  chronic  communal  state  of 
hypochondria.  In  some  of  these  places  the  poetic  hy- 
perbole of  Channing  has  literally  come  true:  "The 
hypochondriac,  shrinking  from  every  breeze,  weighing 
his  food  and  fearing  exhaustion  from  fatigue,  loses  all 
animation."  The  scales  are  on  the  table  and  the  food 
is  not  only  weighed,  but  its  value  in  calories  is  added 
up  to  complete  the  meal  or  feed. 

It  seems  to  me  that  the  modern  tendency  for  every 
man  to  become  his  own  doctor  is  most  productive  of 
an  abnormal  state  of  mind  and  body.  Better  that  every 
man  were  his  own  lawyer,  his  own  electrician,  his  own 
plumber,  his  own  engineer.  The  constant  direction 
of  the  mind,  especially  of  the  young  and  the  idle,  to 
the  functions  of  living,  especially  to  eating  and  drink- 
ing, upsets  the  intellect.  The  subtle  intropulsion  of 
the  attention  by  so  otherwise  harmless  a  fad  as  Fletch- 
erism  has  begun  a  course  of  hypochondria  which  a 
dozen  Emmanuel  movements  cannot  efface.  The 
healthy  stomach  becomes  incompetent  and  sick  when 

243 


244  ESSAYS. 

it  is  supplied  with  an  insufficient  or  monotonous  diet, 
and  after  that  the  man  is  sick.  (By  stomach  is  here 
meant  the  whole  digestive  apparatus).  The  most  ter- 
rible and  obstinate  case  of  scurvy  the  writer  ever  saw 
in  an  adult  was  not  in  corralled  laborers  under  con- 
tract, but  in  a  man  who  voluntarily  followed  too  closely 
his  medico-sacredotal  leader. 

Irreparable  damage  has  been  done  thousands  of  chil- 
dren by  cocksure  physicians  who  have  attempted  to 
prescribe  an  artificial  diet  for  babies  they  wisely  or  un- 
wisely removed  from  the  breast.  Conditions,  less  se- 
rious at  the  outset  than  the  toxemia  known  as  cholera 
infantum,  have  been  fixed  upon  the  helpless  victim  for 
life. 

The  present  study  of  diet  is  based  on  so  imperfect 
a  physiologic  and  chemic  basis  that  it  must  be  applied 
cum  grano  sails.  The  function  of  the  physician  is  to 
stand  between  his  patient  and  uncorrected  scientific 
indications.  In  nothing  is  this  more  true  than  in  diet. 
Whatever  diet  you  prescribe,  let  it  be  for  a  definite 
and  rather  short  time.  Then  let  the  patient  eat  what 
is  set  before  him  and  ask  no  questions. 

Each  people  have  a  diet  which  unthinking  experi- 
ence has  balanced  up  to  the  mean  physiologic  require- 
ment. When  traveling,  therefore,  it  is  best  to  follow 
the  custom  of  the  table  at  which  you  find  yourself  sit- 
ting rather  than  undertake  to  live  as  you  do  at  home. 
The  Italian  cuisine  needs  wine,  the  German  beer  and 
the  Chinese  tea.  It  may  be  that  each  of  these  menus 
is  eccentric  and  produces  corresponding  national  traits 
and  tempers,  but  each  is  better  than  anything  an  indi- 


BLESS   THE  COOK.  245 

viclual  away  from  home  can  command,  even  though 
the  Sultan  of  Sokoto  or  the  Mandarin  of  Ho  Nan  with 
suite. 

Many  things  that  custom  irrationally  dictates,  sci- 
ence adequately  elucidates  and  explains.  Take  the 
table  of  any  family  where  the  mother  is  "a  good 
cook."  Notice  the  almost  perfect  division,  or  better, 
assembling  of  the  meal.  The  live  and  cooked  foods; 
the  solids  and1  the  liquids;  the  hydrocarbons,  the 
albuminoids  and  the  fats ;  the  nourishing,  the  res'dua' 
and  the  stimulating,  and  the  hot  and  the  cold;  what 
chemist  can  equal  it? 

It  is  doubtful  if  any  internist  would  undertake  to 
devise  three  meals  a  day  for  a  table  of  five  and  keep 
it  up  for  six  years,  with  due  consideration  for  stress 
of  weather  and  exigencies  of  the  market.  Certainly 
no  instructions  given  in  the  office  to  relatively  healthy 
persons  can  do  more  than  upset  the  cook's  empirical 
program. 


JAUNDICE  IN  THE  NEW-BORN. 


THERE  is  no  symptom  more  ominous  to  the  parents 
and  the  physician  alike,  which  the  infant  is  apt  to 
manifest  than  jaundice.  In  the  great  number  of  cases 
this  symptom  passes  off  in  a  few  hours,  and  is  due 
probably  to  the  traumatism  of  birth  acting  upon  the 
largest  gland  in  the  body.  The  jaundice,  which  comes 
on  later,  and  is  associated  with  infection  of  the  cord, 
is  common  enough  to  give  rise  to  the  popular  terror 
which  this  symptom  excites. 

There  are,  however,  a  number  of  conditions  in 
which  jaundice  of  the  new-born  appears  that  are  of 
sufficient  frequency  and  pathological  significance  to 
be  worthy  of  discussion.  In  some  of  these  cases, 
terminating  in  death  in  the  course  of  a  few  weeks 
or  a  few  months,  there  is  a  congenital  absence  or  im- 
pervious deformity  of  a  considerable  part  of  the 
biliary  tract,  the  common  duct  and  the  gall-bladder, 
the  cystic  duct,  or  a  small  portion  of  the  common  or 
hepatic  ducts. 

In  Ic>o6  Geissner  presented  a  thesis  to  the  Uni- 
versity of  Halle  on  "The  Congenital  Obliteration  or 
Absence  of  the  Common  Duct,''  and  thus  called  the 
attention  of  pathologists  and  physicians  to  the  sub- 
ject. John  Thompson,  in  several  communications 
and  in  his  exhaustive  article  on  "Congenital  Oblit- 
erations of  the  Bile-Ducts,"  in  Allbutt's  "System  of 
Medicine,"  greatly  elucidated  the  subject.  He  has 
utilized  the  experience  of  obstetricians  and  patholo- 

247 


248  ESS  A  YS. 

gists,  and  shown  that  the  condition  is  one  that  merits 
consideration,  both  from  a  medical  and  from  a  patho- 
logical standpoint.  Generally  the  cases  are  isolated, 
but  in  a  few  instances  they  have  appeared  in  twins 
or  in  two  or  three  members  of  the  same  family.  In 
some  instances  the  parents  have  been  shown  to  be 
syphilitic,  and  it  is  bel'eved  that  with  the  use  of  the 
Wassermann  reaction  a  more  absolute  diagnosis  can 
be  made,  and  thus  a  recurrence  at  a  subsequent  preg- 
nancy can,  by  suitable  therapy,  be  effectually  pre- 
vented. In  a  great  number  of  cases  the  parents  have 
manifested  evidence  of  hereditary  syphilis.  Some 
of  the  parents  were  simply  under-nourished,  and 
nearly  all  the  mothers  complained  of  stomach  trouble 
or  suffered  with  severe  nutritional  disturbance. 

About  one-fourth  the  infants  themselves  were 
jaundiced  at  birth,  and  the  rest  became  so  in  the  first 
few  days  of  life.  In  a  considerable  number  of  cases 
there  was  a  discharge  of  normally  colored  meconium 
which  at  the  next  movement  of  the  bowels  was  fol- 
lowed by  colorless  feces  having  a  very  offensiv  o-1~ 
Other  cases  seemed  perfectly  normal  in  all  respects 
for  a  few  days,  then  jaundice  and  clay-colored  stools 
appeared.  Coincident  with  the  appearance  of  the 
jaundice  and  the  clay-colored  stools,  bile  appeared  in 
the  urine.  The  great  bulk  of  the  cases  showed  hem- 
orrhagic  tendencies  from  the  first,  and  many  died 
from  umbilical  or  from  intestinal  hemorrhage.  It 
would  be  worth  while  to  secure  an  autopsy  and  an 
examination  of  the  common  duct  in  all  cases  of  death 
from  umbilical  bleeding.  The  liver  and  spleen  uni- 


JAUNDICE  IN  THE  NEW-BORN.  249 

formly  enlarged  if  the  child  lived  long  enough.  Most 
often  the  child  died  inside  of  six  weeks,  but  some 
lived  as  many  months.  They  became  terribly  emaci- 
ated, bleeding  or  blebs  appeared,  and  they  suffered 
of  accidental  terminal  diseases  or  died  of  exhaustion. 

Thompson  could  find  only  sixty  cases  reported  in 
the  literature,  many  very  incompletely.  The  authors 
reported  the  obliteration  of  the  duct  as  due,  in  their 
opinion,  to  various  causes;  namely,  to  congenital 
defect,  to  syphilis,  or  to  injury  or  infection  before, 
during  or  immediately  after  birth. 

It  is  certain  that  obliteration  or  absence  of  the  bil- 
iary tracts  occur  in  fetuses  where  there  are  extensive 
congenital  arrests  of  development.  (Wetzel,  Zentral- 
blatt  f.  Gyn.,  1880,  p.  561.) 

A  presumptively  healthy  condition  of  the  child  at 
birth  does  not  preclude  isolated  congenital  error  in  the 
bile  tracts,  for  other  more  serious  errors  are  found  in 
apparently  well  children. 

It  is  difficult  to  make  the  diagnosis  without  an  au- 
topsy, but  in  the  more  recently  reported  cases  the 
diagnosis  of  syphilis  was  indubitable.  The  thera- 
peutic diagnosis  has  been  made  in  several  by  the  use 
of  anti-syphilitic  remedies.  One  observation,  where 
twins  were  thus  treated  after  the  diagnosis  of  syph- 
ilitic obstruction  of  the  common  duct  was  made,  the 
rare  fortune  of  an  autopsy  on  one  twin,  and  the  re- 
covery of  the  other  followed.  When  we  consider  that 
patients  recovered  under  mercurial  treatment  that 
presented  the  gravest  symptoms,  this  observation  was 
almost  as  good  as  an  autopsy  in  vivo. 


250  ESSAYS. 

The  fact  that  some  of  the  patients  appeared  to  be 
well  and  then  became  sick,  seems  to  make  gastro- 
intestinal infection  a  possible  cause;  but  none  of  the 
histories  were  given  in  which  this  factor  was  made 
out.  Enteritis  appears  as  a  secondary  symptom  in 
all  the  cases  that  lived  long  enough  to  manifest  it. 

Boys  are  affected  more  often  than  girls — three  to 
two.  Only  one  of  Thompson's  cases  was  stillborn. 
Eleven  lived  less  than  a  week,  eight  more  than  a  week 
but  less  than  a  month,  fourteen  one  to  four  months, 
sixteen  four  months  to  eight  months,  and  two  more 
than  eight  months. 

From  a  surgical  standpoint,  the  demonstration  of 
these  serious  and  scarcely  viable  conditions  of  the 
biliary  tract  carry  a  serious  lesson.  Such  extensive 
lesions  occurring  so  infrequently  must,  by  the  law  of 
chance,  be  attended  .by  less  serious  lesions  occurring 
far  more  frequently.  These  children  live  and  reach 
maturity  exposed  in  a  greater  degree  than  perfectly 
formed  individuals  to  the  dangers  of  infection  of  the 
biliary  tract.  Any  syphilitic  stenosis  or  congenital 
deformity  of  the  common  duct  would  delay  the  pas- 
sage of  infection  or  calculi,  and  thus  precipitate  a  con- 
dition requiring  surgical  relief  under  circumstances 
which  would  not  eventuate  in  the  well- formed.  The 
cystic  duct  itself  is  sufficiently  complicated  without 
the  possibility  of  a  malformation  or  defect  of  a  con- 
genital nature.  The  part  which  congenital  malfor- 
mation plays  in  the  production  of  cholecystitis  has, 
for  obvious  reasons,  never  been  demonstrated.  The 
analogy  of  this  tortuous  canal  to  the  Fallopian  tube, 


JAUNDICE  IN  THE  NEW-BORX.  251 

to  the  appendix,  to  the  ureter  and  to  the  ducts  of  the 
sweat  glands,  has  required  us  to  consider  it,  but  the 
possibility  of  syphilis  has  not  received  much  attention 
in  the  etiology  of  cholelithiasis.  The  facility  and  pos- 
itive nature  of  the  Wassermann  test  ought  to  furnish 
new  light  in  a  large  number  of  cases  where  infectious 
cholecystitis  comes  up  for  diagnostic  consideration  or 
surgical  treatment. 


DEATH  FROM  ACAPNIA. 


ONCE  in  a  while  medical  literature  is  presented  in 
such  a  form  as  to  fulfill  all  the  requirements  of  a  con- 
tribution to  science,  a  masterpiece  of  literary  art,  and 
a  good  newspaper  story.  Such  seems  to  us  to  be  the 
recent  article  by  Yandell  Henderson,  entitled  "Fatal 
Apnoea  and  the  Shock  Problem."  (Bulletin  of  the 
Johns  Hopkins  Hospital,  vol.  2,  p.  236.) 

The  surgeon  is  conspicuously  conservative  and  es- 
sentially conventional.  He  fixes  upon  a  ceremonial 
and  insists  upon  a  routine.  These  ceremonials  he  is 
loathe  to  break  through.  Now  and  then  changes  be- 
come inevitable,  but  the  very  difficulty  of  their  initi- 
ation secures  them  a  recognized  position. 

Anesthesia  fought  its  way  into  the  operating  room 
and  then  began  the  unfinished  and  inexorable  conten- 
tion between  anesthetists  for  a  monopoly  of  material 
and  method.  No  single  detail  is.  so  much  the  despair 
of  the  operator  as  the  anesthetic.  No  other  office  is 
beset  with  so  many  intractable  and  uncomputable 
variables.  If  an  operator  could  trust  his  anesthesia  he 
could  undertake  with  composure  and  complacency 
the  most  desperate  surgical  adventures. 

Now  comes  Mosso  before  the  surgical  court  with  a 
new  word,  akapnia  (a-kapnos,  without  smoke),  and 
a  new  cause  of  death.  Hereafter  this  word  must  be  a 
conspicuous  danger  flag  in  every  operating  room,  and 
a  bete  noir  to  every  anesthetizer.  The  traditions  of 
the  anesthetizer  s  table  are  broken  in  upon  once  more. 

253 


254  ESS  Ays. 

With  the  departure  of  the  ever- ready  hypodermic  of 
strychnine  must  go,  if  Henderson's  article  is  read,  the 
tank  of  pure  oxygen. 

In  a  most  charming  manner  the  Yale  professor  tells 
the  story  of  death  from  carbon  dioxide  starvation. 
Our  junk-pile  of  physiologic  theories  occasionally  fur- 
nishes a  sprocket  or  cam  that  fits  for  the  requirements 
of  the  vital  mechanism.  The  theory  of  the  excitation 
of  the  center  of  respiration  by  CO2  is  one  of  these.  If 
from  any  cause  the  CO2  falls  below  a  certain  propor- 
tion in  the  blood,  that  center  is  sparkless,  fails  to  act 
and  respiration  ceases. 

A  man  suffers  a  crushing  injury  of  the  hand.  Pain 
causes  unusual,  excessive  and  rapid  respiration.  The 
carbonic  acid  gas  disappears  from  the  blood.  When 
the  patient's  pain  is  relieved  by  time,  by  morphine  or 
by  a  general  anesthetic  and  the  peripheral  irritation  due 
to  the  injury  fails  to  excite  the  respiratory  center, 
the  act  of  respiration  ceases,  the  breathing  stops.  The 
heart  continues  to  he.at  and  the  blood  pressure  is  still 
high  for  quite  a  time — eight  to  fifteen  minutes.  Then 
the  countenance  becomes  blue  and  turgid,  the  heart 
stops  and  the  man  is  dead — dead  for  the  lack  of  car- 
bon dioxide — dead  from  acapnia. 

If  in  such  a  case  the  blood  is  examined  for  its  con- 
tained gases,  it  will  be  found  deficient  in  CO2,  below 
the  amount  necessary  to  excite  the  respiratory  center. 
The  circulation  of  the  blood  after  the  cessation  of  res- 
piration, which  continued  for  eight  minutes  or  more, 
did  not  generate  enough  CO2  to  bring  this  fluid  to  a 
CO2  concentration  at  which  it  could  stimulate  the  res- 


DEATH  FROM  ACAPNIA.  255 

piratory  center  to  a  renewal  of  respiration.  Could  one 
have  aroused  this  center  to  activity  by  peripheral  irri- 
tation (stretching  of  the  anal  sphincter?)  or  by  inject- 
ing some  carbonized  normal  salt  solution  or  other  fluid 
rich  in  CCX  into  the  circulation,  the  man  might  have 
lived. 

Hyperpnea  has  a  most  unexpected  termination.  The 
CO2  in  the  blood  is  normally  twice  as  abundant  as  the 
O,  volume  for  volume.  In  forced  respiration  the  CO2 
disappears  below  the  point  of  exciting  the  respiratory 
center  before  the  hyper-oxidation  produces  recogniza- 
ble symptoms.  If  a  person  is  in  a  clean  atmosphere 
and  has  the  determination  and  physical  endurance  to 
continue  forced  respiration  and  inspiration  long  enough 
we  conceive  he  can  become  physically  exhausted  and 
then  having  stopped  forced  respiration,  automatic  res- 
piration will  not  be  resumed  because  of  his  condition 
of  acapnia,  and  in  the  state  of  perfect  ecstasy  and 
comfort  \vhich  this  condition  produces,  he  will  die  at 
the  end  of  ten  or  fifteen  minutes,  asphyxiated,  without 
the  slightest  sensation  of  lack  of  air  or  the  slightest 
effort  at  respiration.  From  all  that  we  personally 
know  of  the  sensation  of  the  acapnic  state  (including 
our  own  ancient  forty  bottles  of  sarsaparilla  before 
breakfast  in  the  morning)  such  a  procedure  could  be 
recommended  to  every  suicide  club  as  a  pleasant 
method  of  taking  off. 

The  patient  struggling  under  the  first  anesthetic  be- 
comes acapnic  before  he  becomes  unconscious.  With 
his  unconsciousness  the  respiratory  stimulus  of  periph- 
eral irritation  and  mental  excitation  disappear.  His 


256  ESSAYS. 

blood  has  already  through  hyperpnea  become  deficient 
in  CO2,  and  therefore  he  stops  breathing,  and,  in  spite 
of  every  effort  of  the  anesthetizer,  he  makes  no  effort 
at  respiration  until  the  CO2  has  been  restored  to  a 
working  minimum.  How  often  we  heard  the  anes- 
thetizer give  the  alarm  that  the  patient  had  stopped 
breathing;  how  many  times  have  we  left  our  opera- 
tion, if  already  begun,  and  joined  in  the  desperate 
efforts  to  produce  artificial  respiration,  ignorant  of  the 
fact  that  we  were  aggravating  an  already  intangible 
acapnia.  In  the  days  of  the  dirty  old  rubber  bags  that 
our  enthusiastic  anesthetizers  once  used  over  their 
ether  cones  these  accidents  were  rare.  Possibly  those 
bags  promoted  pneumonia,  but  they  prevented  acapnia. 
Henderson  recommends  that  \ve  have  paper  bags  to 
cover  the  ether  cone  when  we  are  anesthetizing  an  irri- 
table or  excited  patient  in  order  that  he  may  breathe 
over  and  over  again  the  atmosphere  burdened  with 
CO2,  and  thereby  avoid  acapnia.  He  further  suggests 
that  when  during  anesthesia  respirations  have  stopped 
and  the  blood  pressure  has  not  yet  fallen  in  shock,  that 
the  operating  room  be  provided  with  oxygen  in  which 
5  or  6  per  cent,  of  CO2  has  been  mixed  and  that  arti- 
ficial respiration  of  this  mixture  be  induced  by  intro- 
ducing a  catheter  into  the  larynx  down  to  the  bifurca- 
tion of  the  trachea.  Thus  a  measured  portion  of  the 
mixed  gases  could  be  given  until  a  sufficient  amount 
of  CO,  stimulation  is  reached  and  the  respiratory 
center  again  takes  on  its  function. 

In  case  of  hyperpnea  from  injury  or  distress,  the 
patient  should  be  smothered  either  by  the  application 


DEATH  FROM  ACAPNIA.  257 

of  a  paper  bag  over  the  nose  and  mouth  or  some  other 
available  material,  and  the  pain  be  as  quickly  as  possi- 
ble relieved. 

"No  idea,"  says  Henderson,  "is  more  firmly  fixed  in 
the  medical  mind  than  the  erroneous  notion  that  the 
respiratory  center  is  sensitive  to  alterations  in  its 
oxygen  supply,"  and  we  may  say  that  nothing  is  more 
shocking  to  the  complacency  of  the  surgeon  and  an- 
esthetizer  than  the  intellectual  discovery  that  a  patient 
may  die  with  an  abnormally  small  content  of  CO2  in 
the  blood,  and  yet  really  die  of  an  oxygen  starvation 
without  the  slightest  hope  of  benefit  from  more  air  or 
more  oxv^en. 


BIBLIOGRAPHY  OF  BAYARD  HOLMES, 

B.S.,  1876;  M.D.,  1884  AND  1888. 

(PREPARED  BY  CARL  vox  KLEIN.) 


HOLMES,  BAYARD.  "The  Bacteriological  Examination  of  an 
Extra-Uterine  Fetus  and  Theoretical  Consideration  of  the 
Bacteriological  Condition  and  Fate  of  Dead,  Retained  Fe- 
tuses." American  Journal  of  Obstetrics  and  Diseases  of 
Women  and  Children,  vol.  xx,  pp.  992-1000,  1887.  Obstetric 
Gazette,  Cincinnati,  1887,  vol.  x,  pp.  462-470.  Weekly  Medical 
Review,  St.  Louis,  1887,  vol.  xvi,  pp.  258-263. 

FENCER,  C.  and  BAYARD  HOLMES.  "Antisepsis  in  Abdominal 
Operations ;  Synopsis  of  a  Series  of  Bacteriological  Studies." 
Journal  American  Medical  Association,  Chicago,  1887,  vol.  ix, 
pp.  444-470.  Also  abstracted  Central  bit.  fiir  Bact.  und  Par- 
asit,  1888,  vol.  iii,  pp.  478-9. 

HOLMES,  BAYARD.  "Destruction  of  the  Trophic  Function  as 
an  Element  in  Determining  the  Localization  of  Infection, 
Especially  in  the  Joint  and  Bone  Diseases."  Chicago  Medical 
Journal  and  Examiner,  1888,  vol.  Ivii,  pp.  129-134. 

"Secondary  Mixed  Infection  in  Typhoid  Fever."  Chicago 
Medical  Journal  and  Examiner,  1888,  vol.  Ivii,  pp.  65-74.  Also 
reprint  same,  Western  Medical  Reporter,  Chicago,  1888,  vol. 
x,  pp.  159-165. 

"Primary  Tumor  of  the  Broad  Ligament,  with  a  Table  of 
Seventeen  Cases."  Journal  American  Medical  Association, 
Chicago,  1888,  vol.  x,  pp.  191-196. 

"Spontaneous  Infection."  Journal  American  Medical  Asso- 
ciation, 1888,  vol.  x,  p.  731. 

"Bacillus  Pyocvaneus."  Western  Medical  Reporter,  1888, 
vol.  x,  p.  188. 

"Report  of  a  Case  of  Primary  Myoma  of  the  Broad  Liga- 
ment with  a  Table  of  Seventeen  Collected  Cases."  Chicago 
Medical  Journal  and  Examiner,  1888,  vol.  Ivi,  pp.  65-73. 

"Report  of  a  Case  of  Gastrostomy."  Chicago  Medical 
Journal  and  Examiner,  1888,  vol.  Ivii,  pp.  330-333.  Also  re- 
print 

"Culture  of  Bacteria  from  the  Urine  of  a  Case  of  Nephritis 
after  Scarlet  Fever."  Journal  American  Medical  Association, 
1889,  vol.  xii,  p.  283. 

259 


260  ESSAYS. 

"On  the  Relation  of  Bacteria  to  Puerperal  Eclampsia." 
Obstetric  Gazette,  Cincinnati,  1889,  vol.  xii,  pp.  341-2. 

"Additional  Notes  on  Secondary  Mixed  Infection."  North 
American  Practitioner,  Chicago,  1889,  vol.  i,  pp.  268-275. 

"Secondary  Mixed  Infection  in  Some  of  the  Acute  Infec- 
tious Diseases  of  Children."  North  American  Practitioner, 
Chicago,  1889,  vol.  i,  pp.  75-83,  121-131. 

"Secondary  Mixed  Infection  in  Typhoid  Fever."  Medical 
Press  and  Circular,  London,  1889,  n.  s.,  vol.  xlvii,  pp.  54- 
56.  Alsi  reprint. 

"Van  Hook's  Operation  for  Tuberculosis  of  the  Sacro- 
Iliac  Joints."  North  American  Practitioner,  Chicago,  1890, 
vol.  ii,  pp.  501-50Z 

"The  Treatment  of  Empyema."  Medical  and  Surgical  Re- 
ports, Cook  County  Hospital,  Chicago,  1890,  pp.  41-75. 

"Secondary  Mixed  Infection  in  Scarlet  Fever."  Virginia 
Medical  Monthly,  Richmond,  1890-1,  vol.  xvii,  pp.  88-91. 

"Hospital  Internes,  Their  Appointment  and  Privileges." 
North  American  Practitioner,  Chicago,  1890,  vol.  ii,  pp.  112- 

"Ruptured  Bladder."  North  American  Practitioner,  Chi- 
cago, 1889,  vol.  i,  pp.  425-427. 

"The  Evolution  of  Infection."  Journal  American  Medical 
Association,  May  6,  1890.  (An  extra  edition  of  100,000 
copies  bound  and  omitted  from  the  index  and  from  the  In- 
dex Medicus). 

"The  Medical  Library  Association  of  Chicago.  The  Medi- 
cal Department  of  the  Newberry  Library."  North  American 
Practitioner,  Chicago,  1890,  vol.  ii,  pp.  209-211. 

"Typhlitis  with  Recovery  by  Perforation  into  the  Rectum." 
Obstetric  Gazette,  Cincinnati,  1890,  vol.  xiii,  pp.  418-419. 

"The  Abuse  of  the  Foot."  (Editorial).  Journal  American 
Medical  Association,  1891,  vol.  xvi,  pp.  451-452. 

"The  Lesson  of  the  Filaria  Sanguinis  Hominis."  (Edi- 
torial). Journal  American  Medical  Association,  1891,  vol. 
xvi,  pp.  345-346. 

"The  Treatment  of  Acute  Anemia."  (Editorial).  Journal 
American  Medical  Association,  1891,  vol.  xviv  pp.  97-98. 

"The  Treatment  of  Acute  Anemia  by  Infusion."  American 
Journal  Obstetrics,  New  York,  1891,  vol.  xxiv,  pp.  281-288. 
Also  reprint.  Abstract,  Journal  American  Medical  Associa- 
tion, 1891,  vol.  xvi,  p.  389. 

"The  Buried  Silk  Suture."  North  American  Practitioner, 
Chicago,  1891,  vol.  iii,  pp.  505-511.  Also  reprint. 


BIBLIOGRAPHY.  261 

"The  Unreasonableness  of  Modern  Dress."  North  Ameri- 
can Practitioner,  Chicago,  1891,  vol.  iii,  pp.  166-176. 

"An  Argument  for  the  Infectious  and  Parasitic  Nature  of 
Carcinoma."  North  American  Practitioner,  Chicago,  1891, 
vol.  iii,  pp.  289-305.  Also,  Surgical  Reports  Cook  County 
Hospital,  1890,  Chicago,  1891,  pp.  59-81. 

"Medical  Literature  and  Literary  Investigation."  North 
American  Practitioner,  Chicago,  1891,  vol.  iii,  pp.  254-258. 

"Empvema. '  Journal  American  Medical  Association,  Chi- 
cago, 1891,  vol.  xvi,  pp.  476-482. 

"On  the  Etiology  of  Extra-Uterine  Pregnancv."  North 
American  Practitioner,  Chicago,  1891,  vol.  iii,  p.  56. 

"The  Outlook  for  Medicine."  University  Magazine,  New 
York,  1892,  n.  80.  Also  reprint. 

"The  Neglect  of  Medical  Education  in  the  Universities." 
Journal  American  Medical  Association,  Chicago,  1892,  voL 
xix,  pp.  259-260. 

"Discussion  of  Prof.  Vaughan's  paper  'On  the  Kind  and 
Amount  of  Laboratory  Work  which  Should  be  Required  in 
Our  Medical  Schools.' "  Association  American  Medical  Col- 
leges' Bulletin,  St.  Paul,  1892,  pp.  19-31,  1  ch.  Journal  Ameri- 
can Medical  Association,  1893,  vol.  xix,  pp.  667-674.  Also, 
reprint. 

"Right  Inguinal  Colotomy  in  a  Case  of  Chronic  Colitis, 
with  Severe  Mental  Symptoms.''  Chicago  Clinical  Review, 
1892-3,  vol.  i,  pp.  306-310. 

"Children  of  the  State."  (Editorial).  Medical  News,  1893, 
vol.  Ixiii,  pp.  551-552. 

"Medicine  at  trie  Columbian  Exposition."  (Editorial). 
Medical  News,  1893,  vol.  Ixiii,  pp.  75-77. 

"Medical  Men  in  University  Settlements."  (Editorial). 
Medical  News,  1893,  vol.  Ixiii,  pp.  103-104. 

"First  Aid  to  the  Injured."  (Editorial).  Medical  News, 
1893,  vol.  Ixiii,  p.  216. 

"A  Study  of  the  Requirements  of  the  Average  Prospective 
Medical  Student  in  1892."  Journal  American  Medical  Asso- 
ciation, 1893,  vol.  xx,  p.  22. 

"A  Case  of  Chronic  Glanders  with  Recovery."  Journal 
American  Medical  Association,  Chicago,  1893,  vol.  xxi,  pp. 
235-236. 

"Is  it  Desirable  and  Practicable  in  Medical  Schools  to 
Teach  Methods  of  Investigation  in  Medical  Literature?" 


262  ESSAYS. 

Medical  News,  Philadelphia,  1893,  vol.  Ixiii,  pp.  171-173.  Also 
reprint. 

"A  Case  of  Carcinoma  of  the  Tongue,  Extending  after 
Two  Partial  Extirpations  to  the  Alveolus ;  Partial  Excision 
of  the  Lower  law;  Partial  Excision  of  the  Tongue;  No  Re- 
currence after  Three  rind  One-Half  Years."  Medical  Re- 
corder, Chicago,  1893,  vol.  v,  pn.  31-32. 

"The  Forthcoming  Report  of  the  Bureau  of  Education  on 
Professional  Education  in  the  United  Sta'  Journal 

American  Medical  Association,  Chicago,  1893,  vol.  xx,  pp. 
39-44.  Also  reprint. 

"A  Case  of  Acute  Osteomyelitis  in  an  Adult  with  Early 
Operation  and  Complete  Cure."  Medical  Xews,  Philadelphia, 
1894,  vol.  Ixv,  p.  668. 

"A  Sti'dv  of  Child  (!ro\vtn,  i,cing  a  Review  of  the  Work 
of  Dr.  William  Townseiid  Porter,  of  St.  Louis."  Xew  York 
Medical  Journal,  1W,  vol.  lx,  pp.  417-423. 

"The  Sources  of  the  Defective,  Dependent  and  Delinquent 
Classes."  Bulletin  American  Academy  of  Medicine,  Easton, 
Pa.,  1894,  pp.  562-572.  Also  reprint. 

"Three  Cases  of  Appendicitis  with  Abscess  Formation  in 
the  Private  Practice  of  One  Day."  North  American  Prac- 
titioner, Chicago  1894,  vol.  vi,  pp.  436-438. 

"A  Proposal  in  the  Interests  of  Higher  Medical  Educa- 
tion." Medical  Xews,  Philadelphia,  1894,  vol.  Ixiv,  pp.  316- 
31& 

"The  Sweat  Shops  and  Smallpox  in  Chicago."  Journal 
American  Medical  Association,  Chicago,  1894,  vol.  xxiii,  pp. 
419-422. 

"Student  vs.  Medical  School."  Medical  Xews,  Philadel- 
phia, 1894,  vol.  Ixv,  pp.  12-14. 

"To  the  Incoming  Stall'  of  the  Co  ike  ('-unity  Hospital,  an 
( )i>|iorti'iiiiy  to  Encourage  Better  Medical  Education  which 
Its  Position  Affords."  Journal  American  Medical  Associa- 
tion, 1894,  vol.  xxii,  pp.  02-63. 

"The  Seminary  Method  in  Teaching  Sui  Bulletin 

American  Academy  of  Medicine,  EastOU,  i'a.,  1895-6,  vol.  ii, 
pp.  572-575.  Also,  Journal  American  Medical  Association, 
Chicago,  1896,  vol.  xxvii,  pp.  3 17-3 IS. 

"\  Case  of  Adenoma  of  the  .\iiiidl  Ear."  Tri-State 
Medieal  Journal,  St.  Louis,  1895.  vol.  ii.  pp.  338-340. 

"School  of  Savagery."  Kind.'  Magazine,  vol.  viii, 

1>.  644,  1895.  A!s<»,  Intelligei 


BIBLIOGRAPHY  263 

"When  Shall  Hysterectomy  be  Performed  in  Puerperal 
Sepsis?"  Journal  American  Medical  Association,  Chicago, 

1895,  vol.  xxv,  pp.  901-908. 

"A  Suggestion  for  a  New  Method  of  Diagnosis  in  Esopha- 
geal  Disease."  Medical  News,  Philadelphia,  1895,  vol.  Ixvi, 
pp.  5SO-581. 

"The  Medical  College  Fraternity,  Nu  Sigma  Xu."  Journal 
American  Medical  Association,  Chicago,  1895,  vol.  xxiv,  pp. 
542-543. 

"The  Medical  Library  for  the  Medical  School,  or  the  Small 
Community."  Bulletin  American  Academy  of  Medicine, 
Easton,  Pa.,  1895,  vol.  ii,  pp.  247-301.  Also  reprint. 

"An  Explosion  of  Tuberculosis  Lymphangitis  in  a  Boy 
Five  Years  Old."  Medical  Xews,  Philadelphia,  1895,  vol. 
Ixvi,  pp.  103-104. 

"Tubercular  Peritonitis."  Annals  of  Gynecology  and  Pedi- 
atry,  Boston,  1895-7,  vol.  xi,  pp.  1-7,  1  plate. 

"The  Seminary  Method  of  Teaching  Surgery."  Journal 
American  Medical  Association,  Chicago,  1896,  vol.  xxvii,  pp. 
317-318. 

"To  be  a  Doctor.''  Journal  American  Medical  Association, 
Chicago,  1896,  vol.  xxvi,  pp.  622-626. 

"Traumatic  Stricture  of  the  Vagina."  Journal  American 
Medical  Association,  Chicago,  1896,  vol.  xxvi,  p.  76. 

"Extra-Uterine  Pregnancy  and  Appendicitis  Complicating 
Pregnancy.''  Xorth  American  Practitioner,  Chicago,  1896, 
vol.  viii,  pp.  443-446. 

"Surgery  of  the  Kidney:  Being  a  Study  of  a  Series  of 
Cases  in  which  Methods  of  Diagnosis  and  Treatment  are 
Illustrated.''  Journal  American  Medical  Association,  Chicago, 

1896,  vol.  xxvii,  pp.  532-541,  650-652.     Also  reprint. 

"Some  Experience  in  the  Diagnosis  of  Surgical  Diseases 
of  the  Kidney,  Ureter,  Bladder,  Prostate  and  Urethra." 
Annals  Gynecology  and  Pediatry,  Boston,  1897-8,  vol.  xi,  pp. 
211-219. 

"Paranephritic  Abscess :  Two  Cases."  North  American 
Practitioner,  Chicago,  1897,  vol.  ix,  pp.  145-148. 

"Surgery  of  the  Kidney:  Being  a  Study  of  a  Series  of 
Cases  in  which  Methods  of  Diagnosis  and  Treatment  are 
Illustrated."  Journal  American  Medical  Association,  Chi- 
cago, 1897,  vol.  xxviii,  pp.  680-682,  769-773.  Also  reprint. 

HOLMES,  BAYARD,  VV'ARFTELD,  E.  D.,  and  W.  PEPPER.  "The 
Relation  of  the  College  to  the  Medical  School."  Bulletin 


264  ESSAYS. 

American  Academy  of  Medicine,  Easton,  Pa.,  1897,  vol.  iii, 
pp.  155-185. 

"Five  Cases  of  Cholelithiasis."  Journal  American  Medical 
Association,  Chicago,  1893,  vol.  xxx,  pp.  775-778. 

"A  Case  of  Sarcoma  of  the  Retro-Peritoneal  Abdominal 
Tissues."  North  American  Practitioner,  Chicago,  1898,  vol. 
x,  pp.  505-508. 

"Adrenal  Tumors  of  the  Kidneys."  (Abstract).  Journal 
American  Medical  Association,  Chicago,  1898,  vol.  xxxi,  pp. 
403-405. 

"Ho\v  Ru'orcile  Modern  Educational  Methods  with  the 
Demands  of  Health."  American  Gynecological  and  Obstet- 
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sion, 69-81).  Also,  Journal  American  Medical  Association, 

1898,  vol.  xxx,  p.  1465. 

"Exopthalmic  Goiter  in  Four  Children  in  the  Same 
Family."  Philadelphia  Medical  Journal,  1898,  vol.  i,  pp.  1117- 
1118. 

"Cerebrosoinal  Pneumococcus  Infection.  Injection  of  De- 
fibrinated  Blood  from  a  Patient  Recovered  of  Pneumonia." 
Journal  American  Medical  Association,  1899,  vol.  xxxii,  pp. 
1360-1361. 

"Hamburg  from  the  Medical  Side."  Journal  American 
Medical  Association,  1899,  vol.  xxxiii,  pp.  529-531. 

"The  Progress  of  Medical  Education.  A  Suggestion  for  a 
Better  Arrangement  of  the  Medical  Curriculum."  Journal 
American  Medical  Association,  1899,  vol.  xxxiii,  pp.  1569-1571. 
Also  reprint. 

"Surgery  of    the   Kidney."       Western    Clinical    Recorder, 

1899,  vol.  i,  No.  2,  pp.  14-25. 

"The  Place  of  the  Lecture  in  Medical  Teaching."  British 
Medical  Journal,  London,  1900,  vol.  ii,  pp.  1033-1034. 

"The  Opportunity  of  the  Smaller  Medical  Colleges.''  Bul- 
letin American  Academy  of  Medicine,  Easton,  Pa.,  1900,  vol. 
v,  pp.  117-118. 

"Can  a  Coal  Miner  Select  His  Doctor?"  Philadelphia 
Medical  Journal,  1900,  vol.  vi,  pp.  769-770. 

"Medical  Education."  Journal  American  Medical  Associa- 
tion, Chicago,  1900,  vol.  xxxiv,  p.  379. 

"Medical  Education."  Journal  American  Medical  Associa- 
tion, Chicago,  1900,  vol.  xxxiv,  p.  240. 

"Medical  Education  in  Indiana."  Journal  American  Medi- 
cal Association,  Chicago,  19CO,  vol.  xxxiv,  p.  241. 


BIBLIOGRAPHY.  265 

x 

"The  Master  of  Medicine  as  the  Teacher  of  Medicine." 
Philadelphia  Medical  Journal,  1900,  vol.  vi,  pp.  378-379. 

"The  Seminary  Method  in  Medical  Teaching."  Journal 
American  Medical  Association,  1901,  vol.  xxxvii,  pp.  741-742. 

"A  Contribution  to  the  Surgery  of  the  Kidney.  Two  Cases 
of  Disease  of  the  Kidney  Simulating  Gall-Stones."  Journal 
American  Medical  Association,  Chicago,  1901,  vol.  xxxvii, 
pp.  172-174. 

"How  to  Use  a  Medical  Library."  Cleveland  Medical 
Journal,  1907,  vol.  vi,  pp.  565-568. 

"A  Case  of  Antrum  Infection  and  Sigmoid  Sinus  Throm- 
bosis without  Present  Middle-Ear  Disease,  presenting  the 
Symptoms  of  Facial  Neuralgia  and  None  of  the  Ordinary 
Symptoms  of  Disease  in  the  Petrosa :  Retropharyngeal 
Gravity-Abscess,  General  Sinus  Thrombosis  without  Much 
Impairment  of  Cerebration.  Death  after  Three  Months. 
Partial  Autopsy.  Presentation  of  Specimens."  American 
Monthly,  1901,  vol.  i,  pp.  385-388.  Also  abstract,  Journal 
American  Medical  Association,  1901,  vol.  xxxvi,  p.  1136.  Also 
reprint. 

"Report  of  a  Death  from  Chloroform  Anesthesia,  being  the 
First  in  a  Practice  of  Sixteen  Years,  and  Including  not  Less 
than  Two  Thousand  Chloroform  Anesthesias."  Journal 
American  Medical  Association,  Chicago,  1902,  vol.  xxxviii, 
pp.  247-248. 

"The  Trend  of  Medical  Education  in  the  United  States." 
American  Medicine,  Philadelphia,  1902,  vol.  iv,  pp.  491-492. 

"A  Primary  Evidement  of  Tubercular  Foci  at  the  Knee ; 
Sudden  Death  after  the  Enucleation  of  Thyroid  Gland  for 
Exophthalmic  Goitre.  Suppression  of  Urine  and  Hemor- 
rhage after  Operation  for  Gall-Stones.  A  Calculus  in  the 
Appendix  Mistaken  for  Ureteral  Calculus."  International 
Clinics,  xii  series,  1902,  vol.  i,  pp.  135-150.  Also  reprint. 

"On  the  Border-Line  of  Surgery."  Fort  Wayne  Medical 
Journal-Magazine,  1902,  vol.  xii,  pp.  95-105. 

"Pyogenic  Inflammation  of  Bone."  Illinois  Medical  Jour- 
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"The  Surgery  of  the  Head."  New  York :  D.  Appleton  & 
Co.,  1903. 

"Case  of  Perforating  Ulcer  of  the  Duodenum;  Operation 
Thirty-two  Hours  After  Perforation.  Death  from  Peritoni- 
tis." Medicine,  Detroit,  1903,  vol.  ix,  pp.  590-595. 

"Intussusception  in  Children."  A.lkaloid  Clin.,  Chicago,  1903, 
vol.  x,  pp.  1078-1085. 


266  ESSAYS. 

"Advantages  of  the  Short  Incision  in  Ideal  Laparotomies." 
Physician  and  Surgeon,  vol.  xxvi,  pp.  534-537.  Also :  Illinois 
Medical  Journal,  Springfield,  1905,  vol.  vii,  pp.  14-17.  Also: 
Chicago  Medical  Recorder,  1905,  vol.  xxvii,  pp.  64-67. 

"The  Surgery  of  the  Abdomen,  Part  I.  Appendicitis  and 
Other  Diseases  About  the  Appendix."  New  York,  1904,  D. 
Appleton  &  Co.,  366  pp.,  8  pi.  80. 

"A  Case  of  Adrenal  Tumor  in  the  Lower  Pole  of  the  Left 
Kidney,  Presenting  Itself  between  the  Colon  and  the  Mesen- 
tery of  the  Small  Intestine;  Removed  Extraperitoneally ; 
Complicated  by  Coincident  Peri-appendicular  Abscess ;  Ap- 
pendicotomy;  Recovery."  Medical  Standard,  Chicago,  1904, 
vol.  xxvii,  575-577. 

"Practical  Points  in  Abdominal  Surgery.  Peritonitis."  Illi- 
nois Medical  Journal,  Springfield,  1904,  vol.  vi,  pp.  499-515. 

"Four  Clinical  Notes  on  Appendicitis."  Alkaloidal  Clin., 
Chicago,  1904,  vol.  xi,  pp.  681-689. 

"Echinococcus  Cyst  of  the  Liver,  with  Report  of  a  Case 
with  Operation  and  Recovery."  Journal  American  Medical 
Association,  Chicago,  1904,  vol.  xlii,  pp.  227-232.  Also  reprint. 

"Appendicitis  with  Peri-appendicular  Abscess  and  Infection 
of  a  Long-standing  Omental  Hernia  in  the  Right  Inguinal 
Region."  Illinois  Medical  Journal,  Springfield,  1904-5,  n.s., 
vol.  vii,  pp.  471-473. 

"Carcinoma  of  the  Intestinal  Tract."  Alkaloidal  Clin.,  Chi- 
cago, 1904,  vol.  xi,  pp.  1113-1119. 

"Suggestive  Therapeutics  as  Practiced  by  a  Surgeon."  Med- 
ical Age,  Detroit,  1904,  vol.  xxii,  pp.  809-815. 

"The  Most  Ancient  Medical  Practice  Laws,  the  Code  of 
Hammurabi,  2200  B.  C."  Journal  American  Medical  Associa- 
tion, Chicago,  1905,  vol.  xliv,  pp.  293-294. 

"The  Importance  of  Cholecystitis  and  its  Relation  to  Dis- 
eases of  the  Upper  or  Cephalic  Peritoneal  Cavity."  Medical 
Standard,  Chicago,  1905,  vol.  xxviii,  pp.  63-66. 

"The  Importance  of  an  Early  Diagnosis  and  Prompt  Sur- 
gical Treatment  of  Cholecystitis  with  or  without  Stone."  Med- 
ical Standard,  Chicago,  1905,  vol.  xxviii,  pp.  120-123. 

"Brown  Atrophy  of  the  Heart  as  a  Result  of  Cholecystitis 
and  a  Complication  of  Cholecystectpmy."  Illinois  Medical 
Journal,  Springfield,  1905,  n.s.,  vol.  viii,  pp.  101-103. 

"Stricture  of  the  Esophagus  from  Spasm  of  the  Cardia." 
Medical  Standard,  Chicago,  1905,  vol.  xxviii,  pp.  180-187. 

"The    Short    Necrosis,    the    Short    Incision    and   the    Short 


BIBLIOGRAPHY.  267 

Stay  in  Bed  After  Ideal  Operation."  American  Medicine, 
Philadelphia,  1905,  vol.  x,  pp.  1025-1029. 

"The  Diagnosis  and  Treatment  of  Infection  of  the  Acces- 
sory Mucous  Cavities  of  the  Respiratory,  Digestive  and  Gen- 
ito-Urinary  Tracts."  Lancet-Clinic,  Cincinnati,  1905,  n.s.,  vol. 
Iv,  pp.  621-626. 

"The  Course  and  So-Called  Complications  of  Cholecysti- 
titis."  Illinois  Medical  Journal,  Springfield,  1905,  vol.  viii,  pp. 
322-330. 

"Indications  for  the  Treatment  of  Cholecystitis."  Medical 
Standard,  Chicago,  1905,  vol.  xxviii,  pp.  533-537. 

"Canalization  of  the  Sigmoid,  Lateral  and  a  Portion  of  the 
Superior  Longitudinal  Sinuses  for  Mastoiditis  of  Twenty-one 
Years'  Standing,  with  Subsequent  Re-establishment  of  a  Tem- 
ppro-mandibuiar  Joint."  Journal  American  Medical  Asso- 
ciation, vol.  xivi,  pp.  99-101. 

"Tubercular  Peritonitis  with  a  Great  Distention  of  Gall- 
bladder." Annals  of  Surgery,  Philadelphia,  1906,  vol.  xliii, 
pp.  790-S01. 

"The  Physical  and  Evolutionary  Basis  of  Marriage."  Jour- 
nal American  Medical  Association,  Chicago,  1906,  vol.  xlvii, 
1886-7. 

"The  Treatment  of  a  Chronic  Arthritis  Resulting  from  a 
Distant  Local  Infection,  Especially  that  of  the  Mucous  Cav- 
ities." Lancet-Clinic,  Cincinnati,  1906,  n.s.,  Ivii,  56-58. 

"The  Hospital  Problem."  Journal  American  Medical  Asso- 
ciation, Chicago,  1906,  vol.  xlvii,  pp.  318-320.  Also  reprint. 

"Ceremonials  and  Festa  in  the  Recreation  of  Larger  Groups 
of  Individuals."  Bulletin  American  Academy  of  Medicine, 

1906,  vol.  vii,  pp.  286-289. 

"The  Running  Ear  and  the  Immediate  Cure  of  Mastqid 
Suppuration.''  Chicago  Medical  Recorder,  1906,  vol.  xxviii, 
pp.  599-604. 

"The  Sense  of  Probability  in  the  Diagnosis  of  Disease." 
Lancet-Clinic,  Cincinnati.  1907,  n.s..  vol.  Iviii,  pp.  346-347. 

"Symptomatic  Toxemia  from  Local  Infection."  Plexus, 
Chicago,  1907,  vol.  xiii,  pp.  499-507.  Also  Lancet-Clinic,  Cin- 
cinnati, 1908,  vol.  xcix,  pp.  5-8. 

"The  Diagnosis  of  Diseases  of  the  Liver  and  Biliary  Ap- 
paratus." Medical  Examiner  and  Practitioner,  Xew  York, 

1907,  vol.  xvii,  pp.  139-141. 

"The  Relation  of  the  State  to  Medical  Education."  Plexus, 
Chicago,  1907,  vol.  xiii  pp.  55-59. 


268  ESS  A  VS. 

"The  Influence  of  Trauma  in  Localizing  Infection  in  the 
Natural  Mucous  Cavities  of  the  Body."  Lancet-Clinic,  Cin- 
cinnati, 1907,  vol.  xcviii,  pp.  430-432. 

"Abscess  of  the  Mesenteric  Lymph  Glands."  Chicago  Med- 
ical Recorder,  1907,  vol.  xxix,  pp.  321-326. 

"A  Case  of  Sigmoid  Sinus  Thrombosis  Without  Conspicu- 
ous Mastoiditis."  Chicago  Medical  Recorder,  1907,  vol.  xxix, 
pp.  143-148.  One  stereoscopic  illustration. 

"The  Neglect  of  the  Anamnesis."  Journal  American  Med- 
ical Association,  Chicago,  1907,  vol.  xlviii,  p.  1349. 

"The  Neglect  of  Pauper  Cases  in  Public  and  Eleemosynary 
Hospitals."  Lancet-jClinic,  1907,  vol.  xcviii,  p.  305. 

"Regurgitation  a  Symptom  of  Gall-stones ;  or,  Rather  of 
Cholecystitis."  Lancet-Clinic,  Cincinnati,  1908,  vol.  c.,  pp.  482, 
483. 

"The  Clinical  'Late  Chloroform  Poisoning'  and  Adolescent 
Insanity."  Medical  Progress,  Louisville,  1908,  vol.  xxiv,  pp. 
357. 

"A  Suggestive  Plan  for  a  Modern  General  Metropolitan 
Hospital  of  P'ive  Hundred  Beds."  Journal  American  Medical 
Association,  Chicago,  1908,  vol.  1,  pp.  1025-1028. 

"In  Memoriam.  Frank  Hugh  Montgomery  (1862-1908)." 
Lancet-Clinic,  Cincinnati,  1908,  vol.  c,  pp.  179-180. 

"The  Unreasonable  Traditions  of  Medicine."  Lancet-Clinic, 
Cincinnati,  1908,  vol.  c,  pp.  133-134. 

"A  Continent  Without  an  Orphan.v  Journal  American  Med- 
ical Association,  1907,  vol.  xlix,  pp.  341-342.  Same :  American 
Medicine,  Burlington,  Vt.,  and  New  York,  1908,  n.s.,  vol.  iii, 
pp.  408-410. 

"The  Toiling  Children."  Medical  Fortnightly,  St.  Louis, 
1908,  vol.  xxxiv,  pp.  545-547. 

"The  Method  of  Sydenham  Greater  than  the  Method  of  the 
Laboratory."  Medical  Fortnightly,  St.  Louis,  1908,  vol.  34, 
pp.  469-470. 

"The  Sentic  Tank  in  Sewerage  Disposal."  Lancet-Clinic, 
Cincinnati,  19C9,  vol.  cii,  pp.  552-554. 

"The  Neglect  of  Medical  Literature."  American  Medicine, 
Burlington,  Vt.,  and  New  York,  1909,  n.s.  vol.  iv,  pp.  175-177. 

"The  Duty  of  the  Physician  in  Raising  the  Standard  of 
Rural  Life."  Lancet-Clinic,  Cincinnati,  1909,  vol.  ci,  311-313. 

"Loss  of  Blood  in  the  Relief  of  Mental  Agony  and  Dis- 
tress." Lancet-Clinic,  Cincinnati,  1909,  vol.  ci,  pp.  434-435. 


BIBLIOGRAPHY.  269 

"Tachycardia  and  Cholecystitis,  with  Section  of  Gall-blad- 
der." Lancet-Clinic,  Cincinnati,  1909,  vol.  ci,  pp.  675-676. 

(Nom  de  plume  E.  Y.  D.,  editorial)  "The  Medical  Book 
Store."  Lancet-Clinic,  Cincinnati,  1910,  vol.  ciii,  p.  32. 

(Nom  de  plume  E.  Y.  Davis,  M.D.,  editorial)  "The  Friends 
of  the  Insane."  Lancet-Clinic,  Cincinnati,  1910,  vol.  ciii,  p.  351. 

"Myositis  Ossificans — A  Lesson."  Editorial,  Lancet-Clinic, 
Cincinnati,  1910,  vol.  civ,  pp.  287-289. 

"Who  Pays  for  Medical  Education  ?"  Editorial,  Lancet- 
Clinic,  Cincinnati,  1910,  vol.  civ,  pp.  124-127. 

"  Orphanotrophism."  Editorial,  Lancet-Clinic,  Cincinnati, 
1910,  vol.  civ,  pp.  238-239. 

(Nom  de  plume  E.  Y.  Davis,  editorial)  "Are  Any  Insanities 
Curable  or  Preventable?"  Lancet-Clinic,  Cincinnati,  1910,  voL 
ciii,  382. 

(Nom  de  plume  E.  Y.  Davis,  editorial)  "The  Physical 
Basis  of  Dementia  Precox."  Lancet-Clinic,  Cincinnati,  1910, 
vol.  ciii,  p.  456. 

(Nom  de  plume  E.  Y.  Davis,  editorial)  "Finding  a  Way 
Out  for  the  Lost  Mind."  Lancet-Clinic,  Cincinnati,  1910,  voL 
ciii,  pp.  479-481. 

"Jaundice  in  New-born."  Editorial,  Lancet-Clinic,  Cincin- 
nati, 1910,  vol.  ciii,  pp.  510-511. 

(Nom  de  plume  E.  Y.  Davis,  editorial)  "The  Condition  of 
the  Blood  in  the  Insane."  Lancet-Clinic,  Cincinnati,  1910, 
vol.  ciii,  pp.  561-563. 

"The  Soul  of  Medical  Education."  Editorial,  Lancet-Clinic, 
Cincinnati,  1910,  vol.  ciii,  pp.  584-586. 

(Nom  de  plume  E.  Y.  Davis,  editorial)  "The  Feeble- 
Minded."  Lancet-Clinic,  Cincinnati,  1910,  vol.  ciii,  pp.  656-8. 

(Nom  de  plume  E.  Y.  Davis,  editorial)  "The  Inhuman 
Method  of  Committment  of  the  Insane."  Lancet-Clinic,  Cin- 
cinnati, 1910,  vol.  ciii,  636-637. 

"The  Indications  for  the  Treatment  of  Calculus  of  the 
Kidney,  Ureter  and  Urinary  Bladder."  Journal  Michigan  State 
Medical  Society,  1910,  vol.  ix,  pp.  4-7. 

"The  Fear  of  the  Cold."  Medical  Fortnightly,  St.  Louis, 
1910,  vol.  xxxvii,  pp.  1-4. 

"Tuberculosis  of  the  Epiphyses  of  the  Femur  and  Tibia ; 
a  Case  Fifteen  Years  after  Evidement."  Lancet-Clinic,  Cin- 
cinnati, 1910,  vol.  ciii,  pp.  284-287. 

"Polycvthemia   Disappearing  after  Removal   of  the  Appen- 


270  ESSAYS. 

dix."  Journal  American  Medical  Association,  1910,  vol.  liv. 
pp.  1207-8. 

"The  Bacillus  Pyocaneus,"  etc.,  etc.  Western  Medical  Re- 
porter, October  1888,  p.  188.  Also  reprint. 

Editorials   in   North   American    Practitioner,   vols.    i-iv. 

"The  Short  Anesthetic,  the  Best  and  Shortest  Operation 
as  an  Added  Indication  for  Prompt  and  Efficient  Treatment 
of  Mastoid,  Anpendiceal  and  Gall-bladder  Infection."  Journal 
Michigan  State  Medical  Society,  June,  1911,  vol.  x,  p.  271. 

"Indications  for  the  Treatment  of  Calculus  of  the  Kidney, 
the  Ureter  and  the  Urinary  Bladder."  Journal  Michigan 
State  Medical  Society,  1910,  vol.  ix,  pp.  4-7. 

"Tuberculosis  of  the  Epiphysis  of  the  Femur  and  Tibia,  a 
Case  Fifteen  Years  after  Evidement."  Lancet-Clinic,  1910, 
vol.  ciii,  p.  284. 

"Polycythemia  Disanpearing  after  Removal  of  the  Appen- 
dix." Journal  American  Medical  Association,  1910,  vol.  liv, 
p.  1207. 

"The  Medical  Library  and  Its  Influence  on  Medical  Cultu'-e 
and  Remuneration.''  American  Medicine,  1910,  vol.  v,  pp.  480- 
483. 

"The  Septic  Tank  in  Sewerage  Disposal."  Lancet-Clinic, 
1910,  vol.  cii,  p.  552. 

"Some  Side  Lights  on  Cholecystitis."  Illinois  Medical  Jour- 
nal, 19C9,  vol.  xvi,  pp.  479-483 ;  also,  International  Journal  of 
Surgery,  1910,  vol.  xxiii,  pp.  33-36. 


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